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ELEMENTS 



OF 



GENERAL PATHOLOGY. 



ELEMENTS 



OF 



GENERAL PATHOLOGY. 



BY A. F. CHOMEL, 

PROFESSOR OP CLINICAL MEDICINE TO THE FACULTY OF PARIS J CONSULTING PHYSICIAN 

TO THE KING ; PHYSICIAN IN ORDINARY TO THE PRINCESS ROYAL J OFFICER OF 

THE LEGION OF HONOR ; HONORARY PHYSICIAN OF THE HOSPITALS j 

MEMBER OF THE ROYAL ACADEMY OF MEDICINE J AND 

OF MANY OTHER ACADEMIES AND LEARNED 

SOCIETIES, NATIONAL AND FOREIGN. 



Melius est sistere gradum quam progredi per tenebras. — Gaubivs. 



THIRD EDITION, CONSIDERABLY ENLARGED. 



TRANSLATED FROM THE FRENCH 

BY F. E OLIVER, M. D., AND W. W. MORLAND. M. D., 

Members of the Massachusetts Medical Society. 




BOSTON: 

WILLIAM D. TICKNOR AND COMPANY 

CORNER OF WASHINGTON AND SCHOOL STREETS. 

M DCCC XLVIII. 



184-8 



Entered according to act of Congress, in the year 1847, by 

F. E. OLIVER, AND W. W. MORLAND. 

in the Clerk's Office of the District Court of the District of Massachusetts. 



BOSTON- 
PRINTED BY THURSTON, TORRY AND CO. 

31 Devonshire Street. 



TO 



JAMES JACKSON, M. D. 

PROFESSOR EMERITUS OP THEORY AND PRACTICE OP PHYSIC IN HARVARD UNIVERSITY, 
HONORARY MEMBER OF THE ROYAL MEDICAL AND CHIRURGICAL SOCIETY, ETC. ETC., 



DISTINGUISHED ALIKE FOR HIS PRIVATE VIRTUES, PROFESSIONAL EMINENCE, 

AND HIS UNWEARIED AND INVALUABLE LABORS IN THE 

CAUSE OF MEDICAL SCIENCE, 

THIS TRANSLATION 

IS, BY PERMISSION, 

MOST RESPECTFULLY DEDICATED. 



TRANSLATORS' PREFACE. 



The classical work now first presented to the medical public 
in the form of a translation, can need no other recommendation 
to secure its cordial reception, than the name and reputation of 
its celebrated author. We may hazard an expression of surprise 
that it has so long remained unclothed with a garb, which 
would have introduced it more universally to the profession in 
this country. With precepts of inestimable value to the student, 
it combines a vast collection of details interesting to the practi- 
tioner. Whoever has followed the author in his clinical practice, 
and remarked his admirable qualities as a diagnostician of dis- 
ease, his unfailing detection of the most obscure symptoms, his 
accurate prognosis, and remarkable skill in exhibiting and ex- 
plaining cadaveric lesions, will readily discover, in the present 
work, the reflection of his practical labors. 

We trust that our task, by no means a light one, has been, at 
least, faithfully performed. The few additions, in the form 
of notes, relate chiefly to new discoveries in medical science, 
announced since the appearance of the last French edition, or 
to questions still undecided, and consequently open to remark. 

Boston, November 12, 1847. 



AUTHOR'S PREFACE. 



General Pathology treats of diseases considered abstractly, 
or in regard to that which is common to them all. It serves at 
once as introduction and sequel to special or descriptive pathol- 
ogy, whose end is the knowledge of each particular malady to 
which man is subject. It comprehends all that is most simple, 
and likewise what is most elevated in science; on the one hand, 
the definition of terms and the description of the phenomena of 
disease ; on the other, the discussion of all those fundamental 
questions and the exposition of those general principles, which 
are to guide the physician in the arduous practice of a pro- 
fession closely connected with the dearest interests of humanity. 
General Pathology, consequently, comprises within itself the 
most unpretending elements and the most exalted philosophy of 
medicine. 

In this new edition we have not departed from the plan and 
rules which were adopted in those preceding it. We have 
treated of disease in general, as we should of any one malady 
in particular, when intending to give the most complete account 
of it possible. 

The definition of disease in general, and the mode of defining 
each one in particular ; the nomenclature, seat, causes, and 
precursory phenomena of diseases ; their symptoms, progress, 
duration, and varied terminations; convalescence, consecutive 
phenomena, relapse, and recurrence ; the distinction of genus, 



X AUTHOR S PREFACE. 

of species, and of pathological varieties ; complications, diag- 
nosis, prognosis, anatomical changes, and treatment ; the inti- 
mate nature of diseases, their classification, and the examination 
of the principal works upon general pathology, are each the 
subject of a special chapter. 

We resolved, in the first edition of this work, to abstain from 
any systematic idea, and to adhere strictly to the narration of 
facts, and the consequences rigorously deduced from them. We 
dare not flatter ourselves that we have completely accomplished 
this, but perhaps may be permitted to think that a near ap~ 
proach to it has been made. In fact, in the midst of the 
immense progress which medicine has made in its positive 
truths, and the great revolutions which it has undergone in its 
theories, we have not erased, in this new edition, anything 
essential of what the first contained, which was published in 
1817, twenty-three years ago. If, however, but little of the 
former has been suppressed, we have been obliged to make, 
in this, the third edition, numerous and important additions. 
Within the lapse of twenty-three years, auscultation has been 
discovered ; percussion, perfected in its manoeuvres, has been 
extended in its applications ; the observation of pathological 
phenomena during life, and the study of anatomical lesions after 
death, have been brought to a degree of precision, which, previ- 
ously, they did not possess, and have furnished us with many 
new facts ; chemistry and the microscope have lent their aid 
to pathology; most positive consequences have been deduced 
from the comparison and enumeration of better observed facts ; 
diagnosis has become more exact, and experiment more rigor- 
ous. We have sought, in this new edition, to omit nothing of 
whatever important conquests have been made by science : this 
has been a long and difficult task, in the midst of the duties of 
medical teaching and the demands of practice. Thus, even 
with the assistance of two young and highly distinguished 
physicians, MM. Dalmas and Grisolle, who have kindly made, 
in the works recently published, the necessary researches for the 



AUTHOR S PREFACE. XI 

present volume, six years have elapsed, from the time when the 
preceding edition was exhausted, to the publication of the 
present one. 

This new edition is far more extended than the second. The 
chapters devoted to the causes, the symptoms, and the progress 
of diseases, have been subjected to important modifications, and 
have received considerable additions. We have given to the 
chapter on Diagnosis a new form and very great development : 
the part relating to therapeutics has been greatly augmented ; 
and we would particularly mention two articles, — one, devoted 
to the exposition of the rules of experiment in medicine ; and 
the other, to the examination of a question sharply contested, — 
the application of the numerical method to pathological facts. 

Paris, October 21, 1840. 



CONTENTS. 



CHAPTER I. 



PATHOLOGY, ITS IMPORTANCE, EXTENT, AND DIVISIONS. GENERAL PATHOL- 
OGY, ITS EXTENT AND LIMITS ; THE ADVANTAGES AND DANGERS ATTEND- 
ING ITS STUDY ; MODE OF ITS EXPLICATION ...... 



CHAPTER II. 

GENERAL AND SPECIAL DEFINITIONS OF DISEASE 



CHAPTER III. 

NOMENCLATURE OF DISEASES. — SYNONYMY. — ETYMOLOGY 



. 13 



SEAT OF DISEASES 



CHAPTER IV. 



16 



CHAPTER V. 



ETIOLOGY, OR THE CAUSES OF DISEASE 

ARTICLE I. 

Determining causes . . 21 

Common determining causes 21 

Circumfusa ... 22 

Applicata .... 23 

Excreta, gesta, percepta . 24 

Specific determining causes 25 

Common specific causes . 25 

Metallic emanations . . 25 

Miasmatic exhalations . 25 

Poisons . ... 26 
Contagious specific causes or virus 26 

ARTICLE II. 

Predisposing causes 

SECTION I. 

General predisposing causes 
Atmosphere 
Winds 

Atmospheric pressure 
Light 
Electricity 
Seasons 

b 



31 

32 
32 
32 
33 
33 
33 
33 



Planetary influences 

Localities . . 

Garments 

Food 

Moral affections 

Political institutions 

SECTION II. 

Individual predisposing causes 

1. Aptitudes 

A. Origin 

B. Age . 

C. Climacteric years 

D. Sex . 

E. Temperament 

F. Constitution 

G. Habits 
H. Occupation 
I. Affluence and poverty 

J. Healthy, convalescent or dis- 
eased condition 
K. Pregnancy 

2. Individual predisposing causes 

proper 



19 

34 
34 
36 
36 
36 
36 



36 
37 
37 
39 
40 
41 
41 
42 
42 
43 
43 

43 
44 

44 



XIV 



CONTENTS. 



A. Circumfusa (dissect'g rooms, 
hospitals, change of climate) 

B. Applicata (clothing, various 
causes of compression, beds, 
baths) 

C. Ingesta (food , drinks, spices, 
condiments, medicaments) 

D. Excreta (evacuations) 

E. Gesta (exercise, repose, fa- 
tigue, want of exercise, watch- 
ing, sleep) .... 

F. Percepta (sensations, pas- 
sions, mental exertion, ante- 
cedent diseases) . . . 



44 



45 

48 
50 



51 



52 



ARTICLE III. 
Occasional or exciting causes . 53 

ARTICLE IV. 
Mode of action of the different mor- 
bific causes . . .55 



Determining causes 
Aptitudes . 

Predisposing causes proper 
Occasional causes 

ARTICLE V. 
Division of diseases relatively to 
their productive causes . 
Innate or congenital diseases . 
Acquired diseases 
Sporadic diseases 
Pandemic diseases 
Endemic diseases 
Epidemic diseases 
Essential diseases 
Symptomatic diseases 

ARTICLE VI. 
Lapse of time between the applica- 
tion of the causes and the de- 
velopment of diseases . . 



55 

57 
58 
63 



64 
64 
64 
64 
64 
64 
65 
69 
69 



69 



CHAPTER VI. 

PRECURSORY PHENOMENA, PRELUDES, ANTECEDENT SIGNS, PRODROMES, OR 
IMMINENCE OF DISEASES 



TO 



CHAPTER VII. 

SYMPTOMS OR SYMPTOMATOLOGY 

ARTICLE I. 
Symptoms furnished by the func- 



tions of relation 



75 



Muscles, (paralysis, tremor, ri- 
gidity, subsultus, carphology, 
convulsions, contraction, etc.) 98 



SECTION I. 



Symptoms furnished by the exter- 
nal appearance . . .75 

A. Attitude . . . .75 

B. Volume of the body . . 76 

C. Growth of the body . . 77 

D. Firmness of the flesh . 78 

E. Color of the skin . . 78 

F. Eruptions . . . .80 

G. Plicatures . . . .80 
H. Tumors, excoriations, fis- 
sures, ulcers, fistula . . 80 

Symptoms furnished by the head . 81 
Symptoms furnished by the neck . 90 
Symptoms furnished by the chest . 91 
Symptoms furnished by the shoul- 
ders . . . . .91 
Symptoms furnished by the abdo- 
men 92 

Symptoms furnished by the organs 

of generation . . .94 

Symptoms furnished by the limbs 95 

SECTION II. 

Symptoms furnished by the organs 

of locomotion . ■ .97 
Bones 97 



SECTION III. 



Symptoms furnished by the voice 

and speech .... 102 

SECTION IV. 

Derangements of sensibility and of 
sensation considered as symp- 
toms ..... 
Internal sensations (pain) 
External sensations . 

A. Sight 

B. Hearing . 

C. Smell 

D. Taste 

E. Touch . 



104 
105 
108 
108 
109 
109 
109 
109 



SECTION V. 



Symptoms furnished by the affec- 
tive functions . . .110 

8ECTION VI. 

Symptoms furnished by the intel- 
lectual functions (delirium) .111 

SECTION VII. 

Symptoms furnished by sleep 
(sleeplessness, dreams, som- 
nolency, coma, etc.) . .113 



CONTENTS. 



XV 



SECTION VIII. 

Lipothymia, syncope, vertigo . 115 

ARTICLE II. 
Symptoms furnished by the inter- 
nal or assimilative functions 116 

SECTION I. 

Symptoms furnished by digestion 117 

A. Hunger .... 117 

B. Thirst . . . .118 

C. Examination of the various 
parts of the mouth . .118 

The teeth . . . .118 

The gums . 119 

The tongue . . .119 

D. Mastication . . . 123 

E. Deglutition . . .123 

F. Stomachal digestion . . 125 

1. Nausea .... 125 

2. Subsultus praecordiorum . 125 

3. Regurgitation . . . 125 

4. Vomiting .... 126 

5. Pain .... 127 
Symptoms furnished by the intes- 
tinal canal . . . 128 

1. Borborygmi . . . 128 

2. Gurgling . . . .128 

3. Passage of alimentary sub- 
stances .... 129 

4. Alvine excretion or defeca- 
tion 129 

5. Excreted substances or ex- 
crements . . . *131 

SECTION II. 

Symptoms furnished by the respi- 
ration .... 134 
1. Frequency . . . 134 

2 Quickness . . . 135 

3. Quantity of air inspired and 
expired . . . .135 

4. Difficulty of respiration . 135 

5. Inequalities of respiration 136 

6. Concomitant sounds . . 136 

7. Qualities of the expired air 137 

8. Auscultation . . . 137 
Modifications of the respira- 
tory murmur . . 140 

Rales . . . .140 
Metallic tinkling . . 145 

Thoracic succussion . . 146 
Pleuritic friction sound . 147 
Auscultation of the voice . 148 
Bronchophony . . . 148 
iEsfophony . . . 149 
Pectoriloquy . . . 150 
Percussion of the chest . 151 
fy II. Respiratory phenomena . 152 

1. Laughter .... 152 

2. Yawning .... 152 

3. Sneezing .... 152 



4. Hiccough . . . .152 

5. Cough . . . .152 
Exspuition . . . 154 
Expectoration . . . 154 
Sputa .... 155 

SECTION III. 

Symptoms derived from the circu- 
lation 162 

$ I. Circulation of the blood . 163 

A. The heart . . . .163 

1. Extent of the heart's pul- 
sations .... 164 

2. Shock or impulse . . 165 

3. Nature and intensity of the 
sound .... 166 

4. Rhythm . . . .169 

B. The Pulse . . . . 170 
Auscultation of the arteries 179 

C. Symptoms furnished by the 
capillary circulation . . 180 

D. Symptoms furnished by the 
venous circulation . . 181 

E. Symptoms furnished by the 
examination of the blood . 182 

§ II. Symptoms furnished by the 

lymphatic system . . 189 

SECTION IV. 

Symptoms furnished by the heat . 192 

SECTION V. 

Symptoms furnished by the ex- 
halations and secretions . 195 
§ I. Exhalations . . . .196 

A. Natural exhalations . . 196 

1. Cutaneous exhalation, or 
perspiration . . . 196 

2. Mucous exhalation . . 198 

3. Serous exhalation . . 199 

4. Exhalations upon the artic- 
ular surfaces . . . 199 

5. Exhalations within the eye, 
the ear, the adipose cells, 
the lymphatic and sanguine- 
ous system, etc. . . 200 

7. Gaseous exhalation . . 200 

8. Sanguineous exhalation . 200 

B. Morbid exhalations . . 200 

1. Haemorrhage . . . 200 

2. Pyogenia . . . .201 
Pus considered in regard to 

its chemical properties 
and its action upon the 
animal economy . . 204 

C. Artificial exhalations . . 206 
§ II. Secretions, properly so called 206 

1. Secretion of tears and the 
fluid of the meibomian folli- 
cles 207 

2. Secretion of the saliva . 207 

3. Secretion of the bile . 208 



XVI 



CONTENTS. 



4. Secretion of the pancreatic 
juice . 210 

5. Secretion of the urine . 210 
Physical and chemical prop- 
erties of the urine . 212 

§ III. Excretions . . .219 

SECTION VI. 

Symptoms furnished by absorption 220 

SECTION VII. 

Symptoms furnished by nutrition . 222 
Augmentation (hypertrophy) 222 
Diminution (atrophy) . . 222 



ARTICLE III. 
Symptoms furnished by the gen- 
erative functions . . . 223 

A. In the male . . . 224 

B. In the female . . .224 

ARTICLE IV. 
Symptoms considered in disease . 226 
Local and general symptoms . 227 
Sympathetic phenomena ; sym- 
pathies .... 227 

Principal and accessory symp- 
toms ... . . .228 

Active and passive symptoms . 229 
Epiphenomena . . . 229 



CHAPTER VIII. 

THE PROGRESS OR COURSE OP DISEASES 



Types . . . . .231 
Acute and chronic course . 233 

Periods in diseases . . . 233 
Invasion ..... 234 
Period of stasis or violence . 235 
Period of decline . . . 235 



. 230 



Circumstances which modify the 
course of diseases (ages, tem- 
perament diurnal revolutions, 
temperature, planetary influ- 
ences, climate, etc.) 



236 



DURATION OF DISEASES 



CHAPTER IX. 



. 240 



CHAPTER X. 



TERMINATION OF DISEASES 

ARTICLE I. 
Different modes of termination 
In the return to health 
In death .... 
In another disease . 
Doctrine of crises 
Seat of critical phenomena 



242 
242 
244 
245 
246 
247 
Precursory signs of critical phe- 
nomena .... 249 



242 

Circumstances which favor or 

oppose critical phenomena . 252 
Duration of critical phenomena 252 
Influence of critical phenomena 
upon the termination of dis- 
eases 253 



ARTICLE II. 
Doctrine of critical days 



256 



CHAPTER XI. 



CONVALESCENCE 



259 



CHAPTER XII. 



CONSECUTIVE PHENOMENA 



262 



CONTENTS. 



XV11 



RELAPSE AND RECURRENCE 



CHAPTER XITI. 



. 264 



CHAPTER XIV. 

THE DIFFERENT GENERA, SPECIES AND VARIETIES OF DISEASES 



266 



CHAPTER XV. 



COMPLICATIONS 



270 



CHAPTER XVI. 



DIAGNOSIS 



273 



273 



fy I. Diagnostic signs . 
$ II. Necessary conditions on the 
part of the patient and the 
physician in forming a diag- 
nosis ..... 
Different modes of exploration 
for forming diagnosis 

1. Pressure .... 

2. Palpation 

3. Touch .... 

4. Succussion 

5. Mensuration 

6. Percussion 

7. Auscultation 

8. Exploration by sounds and 
probes .... 

9. Exploration by specula 
10. Examinations with the mi- 
croscope and the magnify- 
ing glass .... 
Employment of chemical 
agents in the diagnosis of 
disease .... 
Mode of examination and 

interrogation of patients for 
the purpose of forming a diag- 
nosis ..... 
Order to be observed in ques- 
tioning patients 
Examination of the existing 
symptoms .... 
Exploration of the head . 
Exploration of the spine . 
Exploration of the auditory canal 304 
Exploration of the nasal fossae . 304 
Exploration of the isthmus of 
the fauces, the larynx and the 
oesophagus .... 305 
Exploration of the chest . . 306 
Exploration of the abdomen . 308 
Exploration of the genital organs 309 



11. 



$111. 



275 

276 
276 

278 
280 
282 
283 
286 
290 

293 
294 



297 



29', 



298 

301 

302 
303 
303 



Exploration of the rectum . 310 
Exploration of the limbs . .310 
$ IV. Principal component ele- 
ments of diagnosis . .311 

A. Determination of the seat of 

diseases . . . .312 

1. Which is the affected organ? 312 

2. The seat of disease being 
known, what is its extent? 314 

3. Which of the elementary 
tissues is primarily affected? 315 

B. Determination of the lesion 316 

1. Nature of the lesion . . 317 

2. Degree attained by the le- 
sion 318 

C. Symptomatic phenomena con- 

sidered in regard to diag- 
nosis .... 319 
§ V. Circumstances which may 
render diagnosis difficult and 
even uncertain . . . 321 

1. Difficult diagnosis on ac- 
count of the period at which 
the physician is summoned 321 

2. Difficulties in diagnosis de- 
pending upon the predomi- 
nance of general phenom- 
ena, or the obscurity or 
absence of local phenomena 323 

The febrile state in relation 
to diagnosis . . . 330 

3. Difficulties in diagnosis re- 
sulting from the infrequency 

of the disease . . . 336 

4. Difficulties resulting from 
complications . . . 337 

5. Difficulties resulting from 

deception . . . 338 
Feigned and concealed dis- 
eases .... 338 



XV1U 



CONTENTS. 



CHAPTER XVII. 



PROGNOSIS ..... 

§ I. Conditions on the part of the 
patient and the physician for the 
formation of the prognosis . 341 

§ II. Prognostic signs . . 342 

1. Diagnosis the original basis 

of prognosis . . . 343 

2. Power of nature and of art 344 

3. Age, previous health, phys- 

ical and moral causes . 344 
Hereditary condition . 345 

Menstruation, pregnancy, 

the puerperal state . 345 

Habitual intemperance . 345 
Excessive evacuations — fa- 
tigue .... 346 
Climate — seasons . . 346 

4. Precursory phenomena . 346 



341 

5. Commencement of diseases 346 
. 347 
. 347 



6. Progress of diseases . 

7. Duration of diseases 

8. Influence of remedies pre- 

viously employed . . 347 

9. Complications . . . 347 
Prognostic value of certain 

symptoms considered sep- 
arately (external appear- 
ance, aphonia, pain, sen- 
sorial disturbance, deli- 
rium, sleep, dysphagia, 
hunger, thirst, meteor- 
ism, involuntary evacua- 
tions, stertorous respira- 
tion, syncope, sweats, 
haemorrhage, parotiditis) 318 



CHAPTER XVIII. 

THE DIFFERENT ALTERATIONS PRESENTED BY THE ORGANS AFTER DEATH . 357 



ARTICLE I. 

Mode of conducting post-mortem 

examinations . . . 358 

Examination of the exterior of 
the body .... 358 

Inspection of the internal organs 359 

Mode of opening the great 
splanchnic cavities . . 360 

Order in which visceral inspec- 
tion should be conducted . 361 

ARTICLE II. 
The principal lesions presented by 

the organs after death . . 365 

FIRST SERIES. 

Lesions of the solids . . . 365 
Inflammation of the various tis- 
sues 366 

Ulcers 367 

Fistula 368 

Gangrene .... 368 
Tubercle . . . .368 
Granulations .... 369 
Cancer 370 



Scirrhus 370 

Melanosis .... 371 

Cutaneous transformation . 372 

Mucous transformation . . 372 

Serous transformation . . 372 

Fatty transformation . . 372 

Fibrous transformation . . 373 

Oseous transformation . . 373 

Cartilaginous transformation . 373 

Corneous transformation . . 373 

Alterations of form . . . 373 

Alterations of volume . . 373 

Alterations of color . . . 373 

SECOND SERIES. 

Alterations of the fluids . . 374 
Alterations of the liquids . . 374 
Alterations of the gases . . 377 

THIRD SERIES. 

Foreign bodies, inanimate and liv- 
ing 378 

Different importance of cadaveric 
changes 379 



CHAPTER XIX. 



THERAPEUTICS .... 

Observation and experience the 
only guides in the study of 
therapeutics . . . 381 
Experimentation, its difficulties, 
the requisite rules in its pur- 
suit 383 



380 

The numerical method applied 

to the study of diseases . 393 

Refutation of the principal ob- 
jections to the numerical sys- 

_ tem . 395 

Experience in medicine . . 403 



CONTENTS. 



XIX 



Physical and chemical theories 
applied to therapeutics . . 405 

ARTICLE I. 

Indications 406 

Conditions productive of indica- 
tions 406 

A. Genus of the disease . 406 

B. Character of the disease . 407 

C. Type of the disease . . 407 

D. State of the vital forces . 408 

E. Intensity of the disease .412 

F. Different periods of the dis- 
ease 412 

G. Particular symptoms . 413 
H. Seat of diseases . .414 
I. Complications . . .414 
J. Causes .... 414 

Temperament, constitution, 
age, sex, profession, hab- 
itual regimen . . . 415 

K. Commemorative circumstan- 
ces 416 

L. Means previously employed 418 



M. Epidemic constitution . 419 
N. Tendency of the disease .419 
O. Influence exercised by the 
disease upon the constitu- 
tion 420 

Possibility of the occurrence 
of several indications in one 
and the same disease . 420 
Preservative indications . 422 

Principal indications in con- 
valescence . . . 423 
Indications furnished by the 
consecutive phenomena . 423 

ARTICLE II. 

Therapeutical means . . . 423 
Therapeutical means, properly 

so termed . . . 424 

Surgical means . . . 424 

Medical means . . . 425 

General or hygienic means . 428 

Means in acute diseases . 429 

Means in chronic diseases . 434 



CHAPTER XX. 

NATURE OR ESSENCE OF DISEASES 435 

Ideas of the humoral pathologists 437 

Ideas of the Solidists 438 

CHAPTER XXI. 

CLASSIFICATION OF DISEASES 442 



CHAPTER XXII. 

PRINCIPAL WORKS UPON GENERAL PATHOLOGY 



444 



451 



ERRATA. 



80, lines 19 and 23, for " vesicula," read vesiculee. 

101, line 16, insert a comma after " attacks." 

115, lines 11 and 32, for " Topor," read Sopor. 

117, line 21, for " boulimus," read boulimia. 

117, lines 24 and 26, dele the parentheses. 

128, line 25, for " sound," read sounds. 

136, note, for ntwi, read nvtw. 

182, line 35, for " Nosographic," read Nosographie. 

186, line 13 from bottom, for "secretions," read secretion. 

189, line 20, for " Seltzar," read Seltzer. 

189, line 4 from bottom, for § I. read § II. 

197, line 30, for " mouldiness," read mould. 

200, line 5 from bottom, for " haemorrhages consist," read hemorrhage consists. 

208, line 7 from bottom, for " after," read of the. 

213, line 30, for " a thousandth," read of a thousandth. 

226, line 14, for " venerens," read venereus. 

229, last line, for (( epigenometa," read epigenemeta. 

231, note, for rpvQs^og, read nvQt^ig. 

300, line 3 from bottom, for " diagnosing," read diagnosticating. 



ELEMENTS 



OF 



GENERAL PATHOLOGY 



CHAPTER I. 

PATHOLOGY, ITS IMPORTANCE, ITS EXTENT, AND ITS DIVISIONS. 

GENERAL PATHOLOGY, ITS EXTENT, ITS LIMITS. ADVANTAGES AND 

DANGERS ARISING FROM ITS STUDY. ORDER ADOPTED IN ITS EXPO- 
SITION. 

Pathology has been denned to be that branch of medicine 
which treats of the classification, causes, symptoms and signs of 
disease. This definition is far from accurate. As it is the pecu- 
liar province of physiology to treat of whatever relates to the 
human body in its normal condition, so pathology includes within 
its limits whatever relates to the same in a state of disease. The 
seat of diseases, the phenomena which precede and follow them, 
their progress, duration and different modes of termination, their 
reappearance, various forms and complications, the changes they 
produce in the texture of organs, their prophylactic and curative 
treatment, &c. &c., are but so many essential points in their his- 
tory, which necessarily fall within the cognizance of pathology,* 
or that branch of medical science, the object of which is the know- 
ledge of disease. 

Of the various branches of the healing art, none to the physician 
is so attractive as a study, none so important in its results, as 
pathology. He views it as a centre, around which are disposed at 
unequal distances the other natural sciences. The study of anat- 
omy and physiology, of chemistry and physics, of botany and 

* n«dos, disease; loyos, discourse. 
1 



2 GENERAL PATHOLOGY. 

materia medica, afford him but an introduction to that of pathol- 
ogy ; he regarding those sciences of far less importance, so soon as 
the latter shall become the object of his special study, viewing 
them rather as accessory sciences, and among the numerous facts 
presented by them, noting only those which are nearly connected 
with the knowledge of disease, and its appropriate methods of 
treatment. 

We would not however exalt the science of pathology at the 
expense of the other branches of natural history ; whatever be its 
importance, and the dignity of its aim, we claim for it no supe- 
riority over the other sciences. Physiology, physics, zoology, &c, 
it will not be denied, are entitled to equal consideration. Inti- 
mately connected as are all these sciences, they reciprocally aid in 
the elucidation of each other, and none among them should be 
allowed the preeminence, although in his estimation who makes it 
his particular study, either will appear of paramount importance. 

Pathology, like the other natural sciences, is without limit ; while 
botany, zoology, physics, chemistry and mineralogy are daily ex- 
tending their domain, the science of disease, also, to the observer, 
appears to be rapidly advancing. Without here referring to the 
ever new and infinite varieties of disease, this must be evident, 
whether we consider the more careful study of causes, the more 
accurate description of symptoms, the more critical examination 
of the circumstances which exert a favorable or unfavorable in- 
fluence upon the progress of diseases, the discovery of affections 
previously unknown or imperfectly described, or lastly, the appli- 
cation of new methods of exploration to the phenomena of disease. 
To cite a recent example, has not the discovery of auscultation, in 
our own time, added to the history of thoracic disease, a multitude 
of phenomena and valuable diagnostic signs, of which we were 
previously ignorant ? Pathology presents for consideration, a mass 
of facts, all the details of which it is beyond the power of the 
human mind to comprehend; it may even be asserted that, throw- 
ing aside its theories and its systems, no one is possessed of all the 
knowledge contained in the records of pathological science. 

This want of correspondence between the extent of the science 
and the capacity of the human mind, has led to results which were 
not unforeseen. It being impossible to increase the mental powers, 
it was attempted to make a division of the science into several 
parts which should be within the reach of our intellectual capacity. 
Hence the numerous divisions of pathology. Of these the most 
important is that distinctive of internal or medical, and external 
or surgical pathology. The diseases of women, of children, of the 
aged, those seated, whether in any of the splanchnic cavities, in 
any of the great anatomical systems, in an apparatus, or single 
organ, &c, have severally undergone subdivision; and eminent 
professional men have deigned to devote themselves exclusively to 
the study of a single class of these affections. But it should be 
recollected that, in no instance, has the investigation of a special 
group of diseases been of profit to the science, except so far as 



GENERAL PATHOLOGY. 



those, who have devoted themselves to these studies, have been 
well versed in the other branches of pathology. Diseases are not 
confined in their effects to single organs, nor can they be discon- 
nectedly studied. 

There is another division, which has had the effect to enlarge 
rather than diminish the range of the science, and which, like that 
adopted by Bichat in the study of anatomy, has extended its lim- 
its. We refer to the division into general and descriptive patholo- 
gy. The object of this is not to divide the science into several 
parts, nor to separate a particular class of diseases from all others. 
General pathology, whose object it is to treat of diseases in the 
abstract, and of whatever is common to them, includes all under 
the same head, studies their general characteristics, causes and 
development, the succession and connection of their phenomena 
observed during life, the appearances after death, and the circum- 
stances which modify their progress, and by which we are enabled 
to prognosticate the changes which will take place in their course. 
Descriptive pathology includes alike all diseases, but presents 
them in a series of groups, in which each affection is described, 
with the appearances peculiar to it, and which serve to distinguish 
it from all others. Hence, it is evident that there is no analogy 
between this division of the subject, and those before mentioned. 
The latter shorten the study, by presenting fewer objects for in- 
vestigation 5 the former leads to the same result without narrowing 
the limits of the science; and not only does it preserve it entire, 
but by presenting, under different aspects, the objects to which the 
attention should be successively directed, we obtain a more accu- 
rate knowledge and a more just appreciation of them. 

This division differs also from the first, in other respects. It is 
possible to devote ourselves exclusively to the study of internal, and 
neglect to a certain extent that of external pathology : so special 
study may be made of those diseases which occur during child- 
hood or old age, while those peculiar to other periods of life are 
neglected. General and special pathology, on the contrary, cannot 
be exclusively studied ; one is but an introduction to the other ; 
both are indispensable to the physician. 

This division of pathology is one, the limits of which are the 
most clearly defined. The consideration of all the phenomena 
common to diseases belongs to general pathology, while whatever 
relates to the history of particular diseases falls within the prov- 
ince of descriptive pathology. Between these two branches of 
pathology, there are however numerous points of contact ; but it 
is not a little singular that most authors who have treated upon 
general pathology, should have introduced, among considerations 
legitimately within the province of that subject, the history of 
particular diseases. Thus the description of plethora is found m 
almost all treatises upon general pathology. Sprengel, in his 
valuable work * upon this subject, goes still farther, and treats 

* Palhologia Generalis. Amstelodami, 1813. 



4 GENERAL PATHOLOGY. 

successively (in the article, Etiology,') of the signs of the various 
fractures, dislocations, and hernise, and describes the various kinds 
of worms which infest the human body, with the signs indicative 
of their presence. While subjects are thus considered in connec- 
tion with general pathology, which are not within its scope, others 
strictly belonging to it are neglected. The nomenclature of dis- 
eases, the circumstances which influence their course, the treat- 
ment, convalescence, and appearances after death, the mode of 
examination and interrogation of patients, are all important points 
in the general history of diseases, which authors have hitherto 
omitted to mention, although as essential to it as the classification, 
causes, symptoms and signs. 

If the division of pathology into general and descriptive, appear 
to some rather to prolong than to abridge the study of diseases, it 
will be an easy task to bring them to a more just conclusion. We 
readily grant that the knowledge of particular diseases is of the 
highest importance, and that the study of general pathology is not 
of equal utility to the practical physician. But admitting for a 
moment, that the latter be wholly valueless to him who is already 
versed in science, it would not be therefore just to conclude that it 
is without profit to the student. Without here referring to the ab- 
solute necessity of his first becoming familiar with a new language, 
the study of general pathology is to him in other respects of man- 
ifest utility ; all is as yet new to him, he should leave no point 
unattained. Diseases possess certain forms in common, they have 
also features which are peculiar to them. Were it not better, we 
would then ask, to present to the beginner, once for all, the vari- 
ous points of doctrine, and the phenomena common to most dis- 
eases, and thereby avoid the necessity of afterward pointing out 
those peculiar to each, than to weary him with tedious and unpro- 
fitable repetitions, which, in the description of each particular dis- 
ease, must necessarily lead to an incomplete examination of the 
same questions ? In short, should he be made acquainted at once 
with the characteristics common to all diseases, or be under the 
necessity of reviewing the same, as often as he should be led to 
the investigation of a particular disease 1 The answer is evident. 

There are still numerous other advantages attending the study 
of general pathology. It gives scope to considerations, favorable to 
the development of the understanding, and an enlargement of the 
views of the student. It briefly points out to him, at the com- 
mencement of his career, the path he should pursue, the objects 
which claim his attention, and the dangers to be avoided ; it also 
indicates the course which should be adopted in the investigation 
of particular diseases ; and lastly, by grouping together these va- 
rious affections, it aids in the elucidation of their history. 

But aside from the advantages, there are dangers connected 
with the study of general pathology. A cursory examination of 
the treatises upon this subject will alone suffice, to show us the 
systems and hypotheses, which have been either substituted for, or 
mingled with, the results of observation or experience. The same 



GENERAL PATHOLOGY. 5 

may be said, it is true, of most medical treatises, whatever be 
their object, as descriptions of particular diseases, and even records 
of observations. But systems properly so called, those great 
hypotheses, by which the universality of facts is understood and 
explained, necessarily proceed from general pathology. The com- 
parison of diseases, the study and comparison of their various 
phenomena, necessarily lead to those general conclusions so 
seductive to the mind, which receives them with dangerous 
facility, proudly proclaiming them as secrets wrested from nature, 
as laws without exception ; and should they afterward be shown 
by facts to be inaccurate or false, to nature rather than to the 
theory is the error ascribed ; the freaks and caprices of nature 
excite astonishment, while the theory is still regarded with admi- 
ration, until some other takes its place, which ultimately shares 
the same fate. When it is considered that general pathology treats 
of subjects abstractly, and that hence it becomes easy to wander 
from the truth, the tendency of this science to the formation of 
those theories by which the progress of medicine has been so 
long impeded, becomes manifest. 

If the knowledge of the dangers be sufficient in order to avoid 
them, we hope that we ourselves have escaped from those to 
which we have just alluded ; but whatever may have been our 
efforts to attain this end, we dare not natter ourselves that we have 
succeeded. Those most averse to theories and hypotheses, have 
not in all cases been able to guard against them ; they have over- 
thrown the hypotheses of others, by substituting those of their 
own invention, and which appeared to them but the legitimate 
results of observation and experience. It was a remark of Gat/bins, 
that it is better to pause, than go blindly forward ; and yet, in 
the same work, he himself becomes enveloped in the mists of 
humorism, and gravely descants upon the chemical and mechani- 
cal acrimonies of the humors. 

If, as we have seen, the province of general pathology has not 
been with certainty determined, and it be necessary to strip it of 
the erroneous and dangerous theories which have till now rendered 
it obscure, it is no less important that a far different course be 
adopted in its exposition, from that hitherto pursued. By refer- 
ring, as has been the case, to nosology or the classification of dis- 
eases, their definition, seat, course, duration and complications, 
subjects are considered under the same head, which should be 
separately studied, and which are as widely different as signs and 
symptoms, from which two distinct branches have arisen ; if, in 
connection with the nosology, the seat, progress and duration of 
diseases, which have but a vague affinity to their classifications, 
be considered, it is not clear why on this, all other branches of 
general pathology should not depend. 

Is the method to be pursued in the study of general pathology 
an important consideration 1 Is it absolutely necessary, for exam- 
ple, in our inquiries, that prognosis be considered before diagnosis, 
or the causes before the seat of disease 1 We think not ; but are 
1* 



O DEFINITION OF DISEASE. 

yet of the opinion that there are certain points in the history of 
diseases, which, before others, naturally claim our first attention. 
The definition of disease, is the first subject which presents itself; 
the study of the progress of diseases should not precede the 
exposition of the symptoms, and the causes more properly come 
before than after the latter ; the diagnostic and prognostic signs 
should follow the symptoms, and the consideration of the treat- 
ment come after the signs. Thus among the various subjects em- 
braced by general pathology, there are those whose relative posi- 
tion is to a certain extent defined, while there are others which 
may be considered with equal propriety at different periods during 
the investigation. 

In the arrangement of the subjects which constitute general 
pathology, it seems to us important that some method be adopted, 
which shall be equally applicable to the study of particular dis- 
eases. This method would thus become more strongly impressed 
upon the mind. It is moreover well known that a uniform method 
powerfully assists the memory, accustoming the mind to a proper 
arrangement of its ideas, and the classification of the new truths 
which are daily presented. 

The following is the order we have adopted in the exposition 
of general pathology. 

We shall first consider the definition of disease in general, and 
point out the rules which should guide us in the definition of dis- 
eases respectively. After some considerations on the nomenclature, 
etymology and synonomy, we shall speak of the seat of diseases, 
their causes, precursory phenomena, symptoms, progress, dura- 
tion and various terminations. We shall thus be led to the ex- 
amination of the doctrine of crises and critical days. Convales- 
cence, the consecutive phenomena, relapse, kinds, varieties and com- 
plications of diseases, diagnosis and prognosis, will be generally 
considered. We shall also devote a chapter to the examination and 
appearances of bodies after death ; and having touched upon the 
fundamental rules of treatment, we shall conclude by offering a 
few remarks on the nature and classification of diseases. — O. 



CHAPTER II. 

DEFINITION OF DISEASE IN GENERAL, AND OF DISEASES RESPECTIVELY. 

There are two kinds of definition, one being an accurate state- 
ment of the nature of a thing, the other a rapid enumeration of 
its principal characteristics. In either case, the definition to be 
correct, should present so clear an idea of the object defined, as 
to render it always recognizable 3 and easily distinguishable from 
all others. 



DEFINITION OF DISEASE. 7 

Of these two kinds of definition, the first, which acquaints us 
with the nature of things, would be preferable to the second, were 
it as certain and general in its application ; but there is a vast 
number of objects whose nature is unknown to us ; and though 
there be those in which it seems to be understood, this knowledge 
is rarely so well established, as to serve as a basis whereon to 
found a correct definition. The second mode of definition con- 
sists rather in a brief description, than a definition of the object. 
It rests on phenomena appreciable to our senses, without reference 
to the nature of the object itself, which is beyond their reach, and 
the knowledge of which can only be attained by abstract reason- 
ing. It has been justly remarked by M. Dumas that abstractions 
mislead the mind, while truth is conveyed to us through the medi- 
um of our senses. The history of all sciences, and particularly 
that of medicine, proves the truth of this assertion. During the 
period when the first mode of definition was employed, the pro- 
gress of science was retrograde ; when, on the contrary, the 
description came to be substituted for the definition, its advance 
was constant. 

I. Disease, as is well known, is that state opposed to health, a 
word the significance of which is familiar to every one. But to 
render an accurate definition is still no less difficult, as is evident 
from the number and variety of those which have been already 
proposed. Many physicians have attempted its definition by 
referring to its nature, or its ultimate cause. Alcmceon de Orotone 
made it to consist in a derangement of the forces, the concurrence 
and harmonious action of which result in health ; Plato, in his 
definition, for forces, substituted elements, and Asclepiades replaced 
the elements of Plato by indivisible corpuscules ; Sylvius viewed 
disease as a reaction of salts ; Brown, a lesion of excitability ; 
Hitter, a galvanic change ; Baumes, a change in the proportion of 
caloric, oxygen, hydrogen, nitrogen and phosphorus; and Broussais, 
an effect of irritation, &£. Most of the other definitions of dis- 
ease, founded upon its nature, are either comprised in those above 
cited, or are so obscure, as to require a long explanation to render 
them intelligible ; they have consequently been omitted in a work 
strictly elementary, and in which such a display of erudition 
would be out of place. Before taking leave of this subject, how- 
ever, due consideration should be given to the definition of disease 
proposed by Sydenham. 

This writer, with all his natural sagacity and soundness of 
judgment, attempted to define disease, according to its peculiar 
nature. " Dictat ratio, si quid ego hie judico"* modestly says 
this eminent physician, u morbum quantum libet ejus causa, humano 
corpori adversantur, nihil esse aliud quam naturce conamen 
materia morbifica exterminationem, in agri salulem, omni ope 
molientis." This definition, although approximating in some 
respects to the present language of the science, is nearly as defec- 

* Sydenham, de morbis acutis in genere, page 19. 



8 DEFINITION OF DISEASE. 

tive as those which preceded it, presenting but a vague idea of 
an indeterminate effort of nature, a power of which we are totally- 
ignorant. Besides, the effort exerted by nature to destroy the 
morbific cause, would rather constitute the remedy, than the dis- 
ease. Finally, this reaction against the morbific cause does not 
always exist, and consequently Sydenham's definition, were it 
correct in other respects, would fail in this, since a definition 
should apply to all cases. 

The nature of disease being unknown, it becomes necessary to 
seek other grounds upon which to found its definition. This 
necessity has been recognized by pathologists of every age. 

Disease has by some authors been denned to be a derangement 
of the functions. To this it has been objected that mere function- 
al disturbance is insufficient to constitute disease, and that there 
are certain phenomena, which are capable of giving rise to the 
former, without producing the latter. A state of general disturb- 
ance ordinarily accompanies the catamenial flow in females, not 
however, amounting to disease. Parturition is attended with 
violent pains, is followed by a flow of blood, together with a 
feeling of weariness and debility, yet without the existence of 
disease. A violent passion, as anger or fright, may give rise to 
extreme functional disturbance, without however inducing disease. 
In old age, the exercise of the functions no longer takes place with 
the same regularity ; the organs of generation become gradually 
unfitted for reproduction, the functions of relation become by de- 
grees enfeebled, the intellectual faculties become clouded, the sen- 
sations blunted, and the step unsteady. The organs of individual 
life themselves become subsequently affected, yet without the 
existence of disease. In the person who has been deprived in any 
way of an eye or an arm, there is not a regular exercise of all 
the functions, yet it is manifest that disease does not exist. A 
sensation of uneasiness in any part, an acute but momentary pain, 
a transient spasm, or involuntary movement, are instances of 
functional derangement, but cannot be considered as diseases. 

Disturbance of the functions alone is then insufficient to constitute 
disease, since even a considerable irregularity in their performance 
is not necessarily incompatible with health. To define health 
therefore to be that state in which all the functions are performed 
with harmony and regularity, is incorrect. There is, as has been 
said, an individual health which is influenced by a variety of cir- 
cumstances. This has been remarked by many physicians and 
has led them to modify the definition under consideration. Some 
have said, that functional derangement to constitute disease must 
be the result of morbific causes.* By others, the epithet preter- 
natural has been prefixed to signify that such functional disturbance 
must be a deviation from the ordinary course of nature.f This defi- 

* Ludwig, Patholog. Instit., page 6. 

■j- The Latin adjective prceternaturalis has commonly been construed by the 
word unnatural; this is far from its true sense : it expresses a deviation from 
not an opposition to, the ordinary course of nature. 



DEFINITION OF DISEASE. 



nition thus modified, is more accurate, but is still susceptible of 
improvement. Every species of functional derangement, in which 
there is a greater or less deviation from the usual order of nature, 
constitutes a disease ; but disease may exist independent of func- 
tional disorder. Hernia, for example, is a disease, but not always 
accompanied by disturbance of the functions. Tubercular degen- 
eration, a very serious disease, may occur in several glands, and 
even in a portion of an important viscus, as the lungs, without 
giving rise to apparent disturbance of the health. It has been 
maintained by some authors, that an anatomical lesion, which 
is not followed by apparent functional disorder should not be 
considered as a disease ; that the disease can only be said to exist 
from the moment when certain phenomena of reaction render 
it evident. Disease, according to them, and M. Littre adopts this 
definition, f is "a vital reaction, either locator general, immediate 
or mediate, against some obstruction, disorder or lesion." According 
to this definition, a change of structure, however considerable, 
in those cases of aneurism at the root of the aorta, which some- 
times become far advanced without causing apparent disturbance 
of the health, would not become a disease till complete perforation 
of the vessel should take place ; while the same lesion, occurring 
in another part of the same vessel, and causing either compression 
upon a neighboring organ, or giving rise to perceptible pulsations 
through the thoracic walls, would constitute a disease almost from 
its commencement. In a fracture, the disease would consist rather 
in the reaction against the lesion, that is, in the pain, difficulty of 
movement, and inflammation which is developed at the surface 
of the fragments and in the contiguous parts, than in the ana- 
tomical lesion itself. These two examples taken from the most 
familiar diseases, show the incorrectness of this definition, which 
has been before pointed out, in considering that proposed by Syden- 
ham, within which it is comprised. 

It follows from these considerations, that it is impossible to 
render a satisfactory definition of disease, without including 
changes of structure, whether accompanied or not by functional 
disturbance. 

Structural changes being in most diseases the principal, and 
functional disorders occurring, as secondary phenomena, it has 
been thought by some physicians that all diseases are necessarily 
connected with a material organic lesion, and that disease, con- 
sidered abstractly, should be defined an alteration occurring in the 
structure of the body. 

It should be recollected that in a great number of diseases, the 
existence of such an alteration is manifest, and is of the highest 
value in the appreciation, as well as in the definition of disease. 
It may be also remarked, that the number of affections, in which 
these changes are found to exist, is becoming more considerable 
in proportion to the advance of medical science, and will ultimate- 

f Dictionnaire de Medecine, ou Repertoire general, vol. xviii., article, Maladie. 



10 DEFINITION OF DISEASE. 

ly become indefinitely increased; in addition to the discoveries 
daily made by pathological anatomists of lesion in the solid parts, 
previously unnoticed, chemistry is leading to similar results, by 
bringing to light important alterations in the fluids which enter 
into the composition of the human body, as the bile, blood, urine, 
&c. The changes observed in the quantity and consistence of 
certain fluids, and particularly the blood (plethora, anemia) ; the 
excessive accumulation of gas, in parts which naturally contain 
it, its formation in parts to which it is foreign, have added to the 
list of diseases, in which a material alteration exists. These 
lesions of the liquid and gaseous fluids, which form a part of the 
human body, deserve to be placed with those of the solid parts ; 
and should, in the absence of lesions occurring in the latter, 
be comprehended, at least by inference in the definition of the 
disease. 

By thus observing the progress of the science, it may be very 
naturally inferred that, in proportion as our means of chemical 
analysis and observation become more perfect, those diseases in 
which hitherto no material lesion has been discoverable, will be 
gradually added to those whose primitive lesion is already known, 
and disease may then be defined to be an alteration occurring in 
the structure of organs. But in medicine, more perhaps than in 
any other science, we must be guided by facts ; and as it often 
happens that this alteration escapes all our means of investigation, 
and the functional disturbance is alone appreciable, and conse- 
quently that alone which, in the present state of our knowledge, 
indicates and constitutes the disease, it becomes necessary, in at- 
tempting its definition, to characterize it by reference both to mate- 
rial lesions and to functional derangement. 

In the former editions of this work, we defined disease to be a 
perceptible change in the position or structure of parts, or in the 
exercise of one or many functions, relatively to the habitual health 
of the individual. 

We have thought proper, for the sake of brevity, to strike out 
the clause relating to the changes of position of organs, since such 
a change cannot be effected, unless there be also structural altera- 
tion of the parts : a hernia can only follow a structural change in 
the parietes of the splanchnic cavities ; dislocation can only take 
place after rupture, or some other alteration in the parts, of which 
the articulation is composed. We would likewise omit the last 
clause of the definition, relatively to the habitual health of the in- 
dividual, as good sense alone indicates this condition, which more- 
over would be more appropriately placed among the considera- 
tions which precede the definition, where it is presented with its 
necessary developments. We have also employed another expres- 
sion in place of the word structure, which does not so well apply, 
in common phraseology, to the changes which occur in the com- 
position and quantity of the fluids, or to alterations in the volume 
of the solid parts, when at the same time unaccompanied by 
manifest alteration of the tissues. It being impossible to define 



DEFINITION OF DISEASE. 11 

disease according to its nature, and to obtain a clear idea of it 
except from what is revealed to us by its phenomena, we give the 
following definition : a perceptible disorder occurring, either in the 
material disposition of the parts composing the living body, or in 
the exercise of its functions.* 

Some authors have endeavored to create a distinction between 
affection and disease, expressions generally employed as synony- 
mous. It has been thought by some that the word affection is 
more appropriately applied to surgical cases, while those strictly 
medical, would be better indicated by the word disease. Others 
have maintained that disease consists in structural lesion, and af- 
fection in the sensible phenomena arising from such lesion. 

Sprengel, who presents this distinction, thinks it should serve as 
a base for the division of pathology into general and special; the 
former treating of diseases, the latter of affections. In the sense in 
which Sprengel employs these two expressions, both belong equally 
to general, and descriptive or special pathology. This distinction 
between affection and disease ought then to be rejected, as con- 
trary to common acceptation, and as rendering the language 
obscure without elucidating the subject. The words affection and 
disease therefore, in medical phraseology, are used synonymously, 
although the latter, considered in its most general sense, admits of 
a different signification. 

II. Having defined disease in general according to the principles 
previously established, we shall proceed to consider the mode of 
defining diseases respectively. These considerations belong to 
general pathology, inasmuch as they apply to all diseases. 

To obtain a correct definition of each particular disease is of far 
more importance, than the attainment of a clear idea of disease in 
general. 

Being ignorant of the nature of diseases respectively, as well as 
of disease in general, it is necessary that we define them also ac- 
cording to their sensible phenomena. 

It has been recently advanced, that a disease can only be defined 
by determining which is the organ affected and the character of 
that affection ; but this kind of definition which can only apply to 
a limited number of diseases, is not strictly a definition. To say 
that pleurisy is an inflammation of the pleura ; tabes mesenterica, 
a tubercular degeneration of the mesenteric glands ; ascites, an ef- 
fusion of serum into the peritoneum ; epistaxis, a haemorrhage from 
the pituitary membrane ; is to give a signification of the word, and 
not a definition of the disease. Another and more serious inconve- 
nience connected with this kind of definition, is the uncertainty in 
respect to the seat of certain diseases, and the conflicting opinions 
among physicians on this point. How various, for example, 

* This definition appears to us more accurate than any other, although defec- 
tive in some respects ; this imperfection is, perhaps, inherent in the subject un- 
der consideration. Health and disease are often confounded. How is it possible 
to define with strict accuracy things not always distinct? 



12 DEFINITION OF DISEASE. 

would have been the definitions of intermittent fever, whose seat 
has been placed in the liver, spleen, stomach, intestines, nervous 
system, skin, vena porta, lymphatic vessels of the mesentery, and 
to what confusion would these contradictory statements have given 
rise ! It is necessary then, in order that the definition be always 
intelligible, to define these affections according to their phenomena. 
There are also cases, in which the manifest cause of diseases be- 
comes an accessory element in their definition : contusions, wounds, 
lead colic, asphyxia, syphilis, variola, &c., cannot be accurately de- 
fined, unless the cause which produced them be indicated. 

In general, in order to the correct definition of a disease, it is 
necessary to collect the greatest possible number of detailed cases, 
relating to it ; to compare them with each other, so as to isolate 
those phenomena Avhich are constant, from those which are simply 
accidental. 

The phenomena which are found to occur in all the cases, or at 
least in the majority, form the characteristic features of the dis- 
ease ; their brief enumeration will present an outline of the latter, 
constituting its definition. 

Some diseases appear with such different degrees of intensity, 
that it would be impossible to include in a common description 
these various forms of the same affection : cerebral haemorrhage, 
for example, gives rise to phenomena so various, according to the 
size of the coagulum, that it is indispensable, in order to give a cor- 
rect idea of this disease, to present a descriptive definition of its 
principal forms, as in natural history, in which the representation 
of a plant or animal is given, in its principal phases of existence, 
and in its various proportions. The remark of Grimaud, that the 
thorough knowledge of a disease is only to be obtained, by study- 
ing it at the age, and in the sex, temperament and climate, which 
observation has shown to be congenial with it, is incorrect; "for," 
says he, " every disease,* like every natural being, appears in its 
true light, and enjoys the whole plenitude of its existence, only when 
formed and developed under a concurrence of circumstances, which 
are analogous to it, and equally tend to favor its production." The 
physician, whose knowledge of a disease only extends to its se- 
verest form, can have but an imperfect idea of it, being acquainted 
only with its exceptional form. It should be studied, on the 
contrary, in all its varieties, and if there be any which deserve 
particular attention, it should first be those of most frequent oc- 
currence, and afterwards those whose characteristics are least ap- 
parent, the former on account of their greater utility, the latter 
because of their more difficult diagnosis. But, we repeat it the 
definition of a disease is only correct, so far as it comprehends all 
the forms which the latter is capable of presenting. — O. 

* Grimaud. Cours de Fidvres, vol. i., p. 2. 



NOMENCLATURE, SYNONOMY, ETYMOLOGY, OF DISEASES. 13 



CHAPTER III. 

NOMENCLATURE OF DISEASES. — SYNONOMY. — ETYMOLOGY. 

I. Nomenclature. There is perhaps no science, the nomencla- 
ture of which is so defective, as that of pathology. This is doubt- 
less, in part, attributable to the very gradual progress made in the 
knowledge of diseases. If, like chemistry, the science of pathology 
had made a sudden and rapid advance, the old terms would have 
been replaced by others formed on more regular bases. But the 
case has been far otherwise, and nothing can be more preposterous 
than the collection of names by which diseases have been desig- 
nated. Some have been named from their known or supposed 
seat, as pleuritis and hypochondriasis ; or from their causes, as 
colds, &c. ; others from the places and seasons in which they ap- 
pear, as the camp, harvest and autumnal, fevers, ( Grant ;) from 
the country where they originated, as the typhus of America ; from 
the people who transmitted them, as the French disease, (a term 
applied by the Italians to syphilis ;) from the animal which com- 
municates it, as vaccinia ; others, from one of the principal symp- 
toms, as hydrophobia, chorea, &c. In eruptive diseases, the color 
of the skin has, in many instances, suggested the name by which 
they are designated ; rubeola and scarlatina are examples. The 
word variola seems to have had the same origin, and to signify 
that diversity of color which the skin presents, when its surface is 
covered with white pustules, or yellowish or brownish crusts, sur- 
rounded by a red and sometimes brown areola, and separated by 
spaces in which the natural color remains unchanged. The par- 
ticular form of certain eruptions, the manner in which they are 
disposed upon the skin, their appearance during the night, have led 
to the adoption of names indicating these different circumstances, 
as miliaria, herpes zoster, epinyctis ; other affections have received 
names relating to their progress or duration, as intermittent, con- 
tinned, and remittent fevers. The insidious form of some diseases 
has caused the term malignant to be applied to them. There are 
others which have been designated, from a sort of resemblance to 
certain products of liuman industry, or some object of natural his- 
tory, as tympanitis, clavus, cancer, polypus, talpa, and elephantia- 
sis. Others have received names indicative of their supposed na- 
ture, as putrid and bilious fevers ; and again, indicative of the 
kind of organic alteration which constitutes the disease, as tubercle, 
melanosis, encephaloid disease ; others have been named from the 
physician who first described them, as Potts' disease, Bright's 
disease. Besides these principal terms, some epithet indicating its 
degree of severity, form, termination or mobility, has been added 
to the name of the disease. Examples of this, are the variola benig- 
2 



14 NOMENCLATURE, SYNONOMY, ETYMOLOGY, OF DISEASES. 

na, apoplexia fulminans, tinea favosa, angina gangrenosa, febris 
ephemera, erysipelas erraticum. 

It is evident from this brief survey, that no rule has been ob- 
served in the selection of the names under which diseases have been 
described, and that incongruity prevails thoughout pathological 
nomenclature. But another and more serious inconvenience which 
it presents, is, that many terms are false, and consequently liable 
to lead to error ; such are those based on the supposed seat of the 
disease, and upon its intimate nature. In some cases, the error is 
still more palpable, affecting some point relative to the origin of the 
disease, or some one of its more apparent phenomena. Thus, the 
disease of Siam, originated in America; the hepatic flux does not 
generally come from the liver, and the fluor albus may be of other 
colors, &c. 

The defects of such a nomenclature are too striking, not to have 
led many physicians to attempt their correction ; but it should be 
remarked, that these corrections have in nearly every case been 
partial, and that M. Piorry has been the first to propose a complete 
system of nomenclature for all diseases, established on uniform 
bases. These partial corrections, failing to produce a proper regu- 
larity, have proved rather injurious than useful. In some cases, 
more appropriate names have been substituted for those which 
were vague or erroneous, but the latter have not been totally aban- 
doned ; so that many diseases have received a variety of names, 
with which it is necessary to become familiar ; no less than twenty 
have been applied to yellow fever. The effect of these numerous 
pathological terms, has been to increase the number of words, 
without aiding in the elicitation of truth. 

Another, and still more serious, inconvenience results from these 
partial corrections ; some authors, not content with adding new 
names to the old, have transferred the same term from one disease 
to another, under the pretext that it was less appropriate to that to 
which it had been previously applied, than to the one which it was 
henceforth to represent. The troublesome results of these pretend- 
ed improvements are easily discernible ; confusion in pathological 
language has been the necessary consequence. 

It will be perhaps asked, if, in the present state of the science, a 
new nomenclature could with advantage be established, and on 
what basis. When we consider the imperfections and incongruity 
of nomenclature, as it now exists, we become convinced of the im- 
portance of substituting a methodical nomenclature, which shall in- 
dicate the characteristic features of each disease, and by which we 
shall be enabled to establish their relations with each other. But 
if it be also considered, how much the difficulties connected with 
the study of the science become increased by such a multiplicity of 
names, and that, in the present state of our knowledge, it is impos- 
sible to present any system of nomenclature, which shall be satis- 
factory to all, as the attempts of M. Piorry sufficiently prove ; and, 
lastly, if we regard the apparent contradictions to which new terms 
give rise, and the unfavorable inferences of the public with respect 



NOMENCLATURE, SYNONOMY, ETYMOLOGY, OF DISEASES. 15 

to the certainty of medicine, we shall be led to conclude that the 
advantages of a new nomenclature would be more than counter- 
balanced by the inseparable inconveniences connected with it. " Si 
nunc imponenda essent nomina" says Morgagni,* " non dubito 
quin plura excogitari possint meliora et cum vero mag is congru- 
entia ; sed proestat, opinor, verum jmstea animadversum docere, 
Vetera autem et usitata nomina retincre." 

There are some circumstances, however, in which it becomes 
necessary to add to pathological nomenclature ; as upon the dis- 
covery of an affection not before described, and also when different 
diseases have been confounded under the same name. In both 
cases, it is indispensably necessary, even the enemies of neologism 
will admit, to seek a new name for the disease just discovered or 
pointed out. 

II. Synonomy. The same disease having, in some instances, 
received a variety of names, and the same name having been 
applied to many diseases by different authors, the study of the 
various names of diseases, with their different significations, has 
become also indispensable. This is, as it were, an artificial 
branch which man has added to pathology, without any real pro- 
fit, though not without necessity. Synonomy of diseases has con- 
sequently become a highly important point in their history, render- 
ing their study more complicated, an irremediable inconvenience, 
but enabling us to avoid much confusion. 

III. The Etymology of diseases is one of the least interesting 
points in pathology. It is, however, like many other things, a 
knowledge of which is of little utility, but ignorance of which 
would be attended with inconvenience. No one doubts that a 
physician may skilfully treat a disease, without being acquainted 
with the origin of its name ; but it is equally certain, that it would 
be embarrassing, and even injurious for him to appear ignorant in 
the presence of some persons, of the etymology of a word which 
he daily employs. An acquaintance with the exact value of the 
terms in common use, is moreover convenient to the physical! ; 
medical phraseology would, otherwise, be to him unintelligible. 
Most of the names which have been applied to diseases, are of 
Greek and Latin origin ; and as the study of these two languages 
should always precede that of medicine, it is rarely necessary 
for the physician to seek the etymology of the terms of which he 
makes use. 

The etymology of the various terms used in pathology but im- 
perfectly indicates the meaning which should be attached to them. 
It rarely gives an accurate, and often presents a totally incorrect 
idea of the disease. Thus the words phlegwqn, and phlegmasia?, 
from ip^Y", ' I burn,' merely give the idea of heat, which is but one 
of the symptoms of the disease ; the word peripneumony, from ticqi, 
'around,' and nvsvftmt], 'lung,' indicates an affection seated around 
the lungs, whereas it consists in inflammation of this viscus itself, 

* Morgagni, Epist. xvi. 14. 



16 SEAT OF DISEASES. 

and not of the surrounding parts. Thus, etymology, in the former 
case, presents an imperfect, in the latter, an erroneous, idea of the 
disease.* — O. 



CHAPTER IV. 

SEAT OF DISEASES. 

It may be remarked generally, that all the constituent parts of 
the human body are susceptible of some change, and consequently 
may become affected with diseases of greater or less severity. The 
susceptibility to the influence of the various morbific causes, varies 
in different organs ; the skin and mucous membranes are of all 
tissues, those in which diseases are most frequently observed. The 
organs which are deeply seated, and which have no direct commu- 
nication with external objects, are less prone than all others to the 
action of disease. 

It is not always easy to determine the seat of diseases, and the 
history of medicine shows how great has been the diversity of 
opinion on this point. During the reign of humorism, . the primi- 
tive seat of most diseases was supposed to be in some one of the 
fluids which enter into the organization of the human body. The 
Solidists, who came afterwards, supposed the humors to be purely 
passive in the phenomena of life, and considered the solids to be 
the seat of all diseases. Time has dealt justly with these erroneous 
opinions, and observation has shown that the exclusive claims of 
both these systems are alike inadmissible. 

It should be recollected that many diseases have a complex seat, 
primarily affecting the solid parts, and afterwards extending to the 
fluids of the body, or vice versa. The first stage of phlebitis pre- 
sents an example of a disease at first confined to a single tissue, 
but soon followed by a secretion of pus from the suffering part ; 
this morbid product being carried along by the circulatory move- 
ment, is mixed with the blood, which becomes altered, and, by its 
effect upon other organs, produces phlegmasia and suppurations. 
In variola, on the contrary, and in the other contagious eruptive 

* Although the etymology of diseases is generally of slight importance, it is not 
in many cases devoid of interest. The names which have been given to diseases 
are often connected with the history of medicine, and the theories to which it has 
given rise ; such are the terms humoral fever , nervous fever . Etymology may also 
give rise to conjectures upon some of the circumstances relating to the particular 
history of a disease, &c. The term morbdli, for example, by which rubeola has 
been designated, would lead us to suppose that there appeared, simultaneously 
with it, another and more severe affection, bearing resemblance to it, which was 
called morbus, a name always given to epidemic diseases. This circumstance 
would add weight to the opinion generally entertained, that rubeola, which origi- 
nated in the same country with variola, first appeared at about the same period. 



SEAT OF DISEASES. 17 

fevers, in which the blood appears to be the primary seat of the 
disease, the eruption makes its appearance upon the skin and mu- 
cous membranes, a few days after this alteration has taken place. 

There are some diseases which affect nearly all the tissues of 
the economy, as, inflammation, cancer, tubercles, and syphilis. 
Others are observed in but a few ; dropsy, for example, is peculiar 
to the membranes which line the interior of cavities, and to the 
cellular tissue ; spontaneous haemorrhage rarely occurs except from 
the mucous membranes. Haemorrhage may, however, take place 
in other parts, and dropsy may be formed, by means of accidental 
cysts, in parts naturally protected from it by their structure. 
There are also other diseases, which appear to be constantly and 
exclusively confined to the same anatomical element, wherever 
this be ; this is probably the case in rheumatism and gout, which 
are peculiar to the muscular and fibrous tissues. 

Many diseases have a fixed seat, that is, they become developed 
and terminate in the same part where they originally appeared ; 
others, on the contrary, successively invade the neighboring parts, 
as certain phagedenic ulcers, cancer, erysipelas, and perhaps most 
of the phlegmasia?, called spontaneous. There are others whose 
seat, which is essentially vague and moveable, is constantly vary- 
ing, as is observed in rheumatism and gout, the mobility of which 
affections constitutes one of their most essential characteristics. 
There are also certain nervous affections, which successively ap- 
pear in parts remote from each other, and haemorrhages are equal- 
ly liable to change their seat. 

There are many diseases which affect but a portion of the 
economy ; there are others, which appear simultaneously in parts 
more or less remote from each other, exhibiting the same form and 
characteristics. The former have but a single seat, the latter are 
disseminated, or have a multiple seat. To the first belong the 
visceral and membranous phlegmasiae, as pneumonia or pericar- 
ditis ; to the second, urticaria, variola, rubeola, the syphilitic 
eruptions, morbus macnlosns, &c. These latter affections, to 
which we have applied the term disseminated, deserve particular 
attention, from the conditions under which they are developed. 
These multiple lesions are indeed almost always secondary, and 
the physician may in most cases recognize the affection which 
gave rise to them, and to which the treatment should be directed. 

The organs which exist in pairs are often simultaneously affect- 
ed with the same disease. It is rare to see spontaneous ophthalmia 
confined to one of the conjunctivae, or bronchitis or emphysema 
affecting but one lung. There are certain chronic exanthemata 
which appear simultaneously in both armpits, in the two groins, 
and in corresponding parts of the same limbs. In rheumatism, 
corresponding articulations become generally successively affected. 
The same law is observed in regard to the deep seated organs. It 
has been clearly shown by M. Bizot, that the numerous changes 
which take place in the arteries, are almost always affected si- 
multaneously in the symmetrical vessels, and at corresponding 
2* 



18 SEAT OF DISEASES. 

points.* There are, however, some exceptions to this law ; the 
two testicles, or the mammse, for example, which often become 
singly affected with inflammation or carcinomatous disease, are 
rarely the seat of either of these affections simultaneously. 

It has been long observed that the age has a marked influence 
upon the seat of diseases. During infancy the head is the seat of 
numerous affections; hydrocephalus, tubercular meningitis, the 
various eruptions of the hairy scalp, excoriations of the lips, nose 
and ears, apthse, grangrene of the mouth, and epistaxis are pecu- 
liar to this period ; the lightest affections are accompanied with 
delirium, the submaxillary glands are often engorged, and the 
larynx is the seat of very serious diseases; it is at this period 
that croup is most commonly observed. At puberty and during 
the period of youth, affections of the chest, as inflammations of 
the pleura and lungs, haemoptysis, and bronchitis, become more 
frequent; it is then that the first signs of cardiac disease often 
manifest themselves, and so common is the occurrence of phthisis 
pulmonalis at this period, that it was for a long time supposed 
never to appear except between the ages of fifteen and thirty. 
While thoracic disease is more frequent during the period of 
youth, that of adult age is more prone to diseases of the abdomen ; 
it is at this period that most organic affections of the abdominal 
viscera become developed ; diseases of the stomach, intestines, 
ovaries, testicles, liver, bladder and uterus rarely occur before this 
time. The haemoptysis of youth, which succeeds the epistaxis of 
childhood, is followed in adult age by the hgemorrhoidal flux, which 
is as peculiar to this period, as the others to the preceding. Lastly, 
in old age, while the abdomen continues the seat of various diseases, 
those of the urinary organs become more frequent, and the head 
again becomes prone to morbific action ; dementia, paralysis, effu- 
sion of blood into the brain, softening of its substance, deafness, 
cataract, &c., are diseases as common during this, as they are rare 
at other periods of life. 

To this observation respecting the frequency of diseases of the 
head, chest and abdomen at particular periods of life, although 
generally true, there are numerous exceptions. Without referring 
to the diseases produced by mechanical causes, whose seat is 
determined by external circumstances, we often see children 
affected with pulmonary catarrh, phthisis, and various forms of 
enteritis. Scrofulous enlargement of the mesenteric glands, and 
intestinal worms, are of more frequent occurrence during child- 
hood than at other periods ; mania, whose seat appears to be in the 
brain, is more common in youth and adult age; simple meningitis 
occurs at all periods of life, and pneumonia is one of the acute 
diseases most frequently observed in old age. But however nu- 
merous the exceptions, they are insufficient to invalidate the gen- 
eral rule. 

It has been stated that the seasons, as well as the age, exert 

* Memoires de la Soc. Med. d'Observation. Paris, 1836, t. 1, p. 399. 



ETIOLOGY. 19 

a marked influence upon the seat of diseases ; that in winter, 
cerebral diseases prevail ; in spring, those of the chest ; while ab- 
dominal affections are more prevalent in summer and autumn. 
This assertion does not so generally apply as the preceding, 
although not without foundation, particularly if it be considered 
with exclusive reference to acute diseases. 

Such are the general points of view, in which the seat of dis- 
eases may be considered, the difficulties and modes of deter- 
mining which, will be particularly considered in the chapter on 
diagnosis. — O. 



CHAPTER V. 

ETIOLOGY, OR THE CAUSES OF DISEASE.' 



The most general signification of Etiology in all the sciences, 
is the study of causes ; in medicine, its object is the knowledge 
of morbific causes. 

Under the title morbific causes, is included every thing which 
produces disease, and all that contributes to its development. 

The causes of disease are everywhere present, both around and 
within us. The things most necessary to our existence, as the 
air we breathe, the food and fluids which restore our daily loss of 
substance, the products of human industry by which life is 
rendered more comfortable and happy, themselves give rise to the 
ills with which we are afflicted. 

The different organs, which united, constitute the economy, and 
which are designed for the preservation of the entire system, of 
which they form part, may also, in certain circumstances, disturb 
its harmony ; the muscles, whose use is to transport us from one 
place to another, may cause displacement and even fracture of 
the bones ; the teeth, the eye-lashes, the nails, by their irregular 
development, sometimes occasion diseases of a more or less seri- 
ous nature ; gestation, and especially the expulsion of the fetus, 
become under certain conditions the sources of danger and death. 
When we thus behold, within the system and without, the things 
most indispensable to human life and to the preservation of the 
species, become in some circumstances the causes of the maladies 
by which we are afflicted, we are tempted to admit with Testa, 
that there is not, properly speaking, any morbific cause, nothing 
in itself injurious : " Nihil proprie morbificum, nihil noxiurn 
natura sua." But this assertion, although true in respect to the 
greater number of causes which disturb the health, becomes the 
opposite, when, reviewing all the causes of disease, we come to 

*Alila y cause ; i-oyog, narration. 



20 ETIOLOGY. 

the contagious principles, which are certainly, in themselves and 
despite the abuse that may be made of them, morbific agents. 

The causes of disease being very numerous and varied, the 
necessity for a division of them has always been experienced : 
they have been divided into external, or those which surround 
the individual ; internal, existing within him ; principal, or 
those which act an important part in developing diseases ; accesso- 
ry, which exert but little influence in their production ; remote, 
which prepare or determine the hidden alteration constituting 
the essence or proximate cause of the disease ; predisposing, 
which gradually modify the economy and dispose to various affec- 
tions ; occasional, which provoke the development of such 
affections. 

The terms physical and chemical, have been applied to those 
causes which act in accordance with the laws of physics and 
chemistry, and which would affect the dead equally with the liv- 
ing body : such are instruments capable of inflicting wounds, 
caustic substances, etc. ; the term physiological is applied to those 
which need the co-operation of a vital reaction in the organ 
which receives their impressions ; local, to those whose action 
affects but a portion of the economy ; general, to those which ex- 
tend their influence over all ; negative, to those which consist in 
the abstraction of conditions necessary to health ; and the oppo- 
site, positive, to those which act by their own power in the pro- 
duction of diseases. Material and immaterial causes have been 
admitted, according as they are or are not recognized by our senses. 
Finally, as there is a certain number of diseases which occur 
without appreciable cause, concealed or occult causes have 
necessarily been admitted, and these have been ascribed by 
many authors to certain inappreciable qualities of the atmosphere, 
to which the development of epidemics may be attributed. 
There are serious inconveniences attending each of these divis- 
ions. The proximate cause, which is nothing else than the very 
essence of the disease and the peculiar modification of the organism 
which constitutes it, cannot be reckoned among the causes which 
produce it. Among the occasional causes, circumstances entirely 
dissimilar are enumerated : the impression of cold, for instance, 
which at one time developes pneumonia, at another, occasions 
anasarca, and which most frequently is productive of nothing 
morbid, is placed in the same category with wounding instru- 
ments and poisons, which always produce definite effects upon 
the system. It is unnecessary to insist upon the imperfection of 
each of these divisions ; neither of them possesses the advantage 
of uniting those causes which have an analogous action ; and yet 
it is this very circumstance which should serve as a foundation 
for the most natural division of morbific causes. 

Among these causes there are those which are constantly fol- 
lowed by the same diseases ; for them we reserve the name deter- 
mining. Others, whose action is often uncertain and always ob- 
scure, may be subdivided into two series. In the first, we place 



ETIOLOGY. 21 

whatever serves, by gradually modifying the economy, to pre- 
pare it for any particular affection, and everything constituting 
the aptitude for being so affected : these are predisposing causes. 

In the second series we rank those whose action, usually tran- 
sient, only hastens the development of a disease, to which the 
patient was predisposed : to the latter we give the name occasion- 
al or exciting causes. 

Thus we admit three orders of morbific causes, which we dis- 
tinguish by the appellations determining, predisposing and occa- 
sional. We shall rapidly review the chief causes which belong 
to each of these three divisions, and shall afterwards offer some 
general considerations upon their mode of action in the production 
of disease. 



ARTICLE FIRST. 
Determining Causes. 

Determining causes, which constantly give rise to the same af- 
fection, if we except certain conditions more or less well known, 
exhibit in almost every instance, either in themselves or in the dis- 
ease which they produce, some peculiarity. The hot body which 
burns, the cold which freezes, the gases which poison or cause 
asphyxia, the body which inflicts a wound, the poison which nar- 
cotizes or causes convulsions, are certainly special causes, in like 
manner as the diseases which they induce are themselves unlike 
all others. This it is which led us in the former editions of this 
work, to class these morbific agents among the specific causes, and 
to use synonymously the terms specific and determining causes. 

Notwithstanding, we now think that a more strict signification 
should be given to these words, and one more in accordance with 
general usage : by specific causes, then, will be understood those 
which produce specific diseases, and by specific diseases, those 
which cannot be developed except by one and the same caitse, as 
syphilis, rabies, variola. Those causes whose action is equally di- 
rect and constant, but which give rise to diseases which other 
causes may also produce, will be designated common determining 
causes ; burns and wounds, for instance, may be produced by vari- 
ous agents. We may add, that the greater part of the common 
determining causes act by virtue of physical or chemical laws, 
and that their action can be explained by these laws. Specific 
causes, on the contrary, in their mode of action, are inexplicable, 
either by means of physics or chemistry. Such are the motives 
which have induced us to divide these two classes of causes and 
to study them separately. 

$ I. Common determining Causes. These may be diffused in 
the atmosphere (circnmfnsa), brought in contact with our bodies, 
(a-pplicata), or introduced into our organs {ingesta) ; they may 
exist within us and depend upon derangement of the evacuations 



22 ETIOLOGY. 

{excreta), of the movements {acta) or of the perceptions {percep- 
ta) ; they will be pointed ont in this order, which is the one most 
commonly followed in the explanation of hygiene, and which is 
equally well adapted to the study of morbific causes. 

A. Circumfusa* In certain circumstances gases unfit for re- 
spiration are introduced into the air passages ; nitrogen, the pro- 
toxide of nitrogen and hydrogen have been inhaled by chemists 
in order to ascertain their effects on the animal economy. They 
produced a mild asphyxia very different from that caused by the 
deleterious gases. These last are sometimes found accumulated 
accidentally in certain places where the external air penetrates with 
difficulty ; as in drains, sewers, mines, certain work-shops, facto- 
ries, and in some thermal establishments. Carbonic acid gas and 
carburetted hydrogen, which are disengaged by the combustion of 
charcoal, may become mixed with the air in sufficient quantity to 
asphyxiate the persons who breathe them. The same is true of 
the gases which escape from animal matters, particularly excrement 
in a state of putrefaction, in a closed vault, by which asphyxia is 
quickly produced. This accident, to which the workmen, who 
are employed in clearing privies are exposed, is occasioned by a 
gas long known as sulphuretted hydrogen, and which seems most 
commonly composed of hydro-sulphuric acid, hydro-sulphate of 
ammonia and nitrogen. Carbonic acid gas accumulated in the 
lowest part of certain caverns, (as in the Grotto del Cane, for in- 
stance) is in that situation several feet in depth ; if a man enter, 
he is above the level of the deleterious gas, but a child would be 
asphyxiated, like the animals which are introduced for experiment. 

Putrid and malignant fevers have at times raged epidemically 
during the disinterment of a large number of bodies : the town of 
Saulieu, in 1773, presented a sad example ;f and long previously, 
an epidemic, gangrenous fever had been observed,! produced by 
tainted air after contagious disease among animals, where great 
numbers of their bodies remained unburied and infected the at- 
mosphere. 

Vegetable emanations are occasionally the determining causes of 
disease. Air charged with the odorous principle of the hyacinth, 
the lily, the orange blossom, the narcissus, causes headache, nau- 
sea, dizziness, and sometimes even fainting, especially in small and 
warm apartments. 

A very high, or exceedingly low temperature of the atmosphere 
is a determining cause of many affections. Individuals exposed to 
severe cold have often been observed to die with symptoms which 
might be ascribed to asphyxia or to strong cerebral congestion ; 

* Properly speaking, morbific agents, diffused in the atmosphere, act only by 
their introduction into our organs, and, thus considered, should, perhaps, be ranked 
with the ingesta ; but it has not been (teemed proper to depart from the classifica- 
tion generally adopted. 

f Maret, Usage d'enterrer les morts dans les eglises. Dijon, 1775. 

j De recondita febriurn remitt. ac intermitt. natura. 



ETIOLOGY. 23 

freezing of a portion of the body is at such a time a yet more fre- 
quent occurrence. The grave symptoms caused by a very elevat- 
ed temperature have also been referred by most physicians to apo- 
plexy or asphyxia ; but, from the researches of some authors, and 
those of J. J. Russel in particular, it seems that the special action 
of heat is a determination towards the thoracic organs, causing vi- 
olent congestion, frequently terminating in death.* 

A very brilliant light suddenly flashing upon the eye, or an ex- 
ceedingly loud noise, may produce blindness, or deafness. 

A violent discharge of electricity diffused through the air, or col- 
lected by apparatus, has caused in some persons sudden death, in 
others, incurable tremor, stupor, or partial paralysis. 

B. Among the applicata a great number of determining causes 
exist. Those bodies which inflict bruises, and pointed and cutting 
instruments, are the most common causes of all the wounds to 
which man is exposed. Falls, in which the human body gtrikes with 
the impetus it has received, against surfaces more or less resistant, 
give rise to diseases, analogous to those produced by vulnerary 
agents. 

In the same class with these latter must be placed ligatures, 
which, in addition to their hindrance of free circulation, may pene- 
trate into the tissues when strongly drawn, and asphyxiate when 
applied over the course of the trachea. 

Immersion in a liquid has a similar effect by preventing the 
ingress of air. Incandescent bodies, and boiling liquids placed 
in contact with our flesh either inflame or cause gangrene, ac- 
cording to their degree of power. Solid or liquid caustics, acids, 
alkalies and salts, act in an analogous manner ; some of these sub- 
stances, as corrosive sublimate and arsenical preparations, may be 
absorbed at the surface of the body at the same time that they act 
locally as caustics ; they may likewise be conveyed into the in- 
ternal organs and give rise to the phenomena of poisoning. In the 
same series may also be placed the acrid topical agents, whether 
rubefacient or vesicant, as the flower of mustard, the powder of 
cantharides, the bark of the Daphne Mezereum, etc., etc. 

C. Ingesta. Substances introduced into the interior of the 
body, become frequently the determining causes of disease. The 
poisons belong almost wholly to this class. By poisons are under- 
stood, according to Mead, all those substances which, in minute 
doses, are capable of producing great changes in living bodies. 
We prefer, with Mahon, to give the name to those only which are 
destructive of life. 

Formerly, poisons were divided into mineral, vegetable and ani- 
mal. M. Orfila has, with reason, considered it more convenient to 
class them according to their mode of action upon the economy, 
rather than after the particular natural kingdom to which they 

* Encycl. des. Sciences Medicates p. 235. 



24 



ETIOLOGY. 



belong. Consequently, he has divided them into four classes, 
according to their properties, viz., irritating, narcotic, narcotico- 
acrid and septic. Irritating, corrosive, escharotic or acrid poisons, 
according to their strength, simply inflame or completely disorgan- 
ize the part to which they are applied. Narcotic poisons, such 
as opium, the solanaceoe, etc., act in an entirely different manner: 
their operation is particularly upon the brain, whose functions 
they disorder or suspend, and they have but little effect upon the 
organs with which they are in immediate contact. Narcotico- 
acrid poisons, such as the poisonous mushrooms, present the above 
two modes of action united. Finally, septic poisons, as the flesh 
of animals who have died of pestilential diseases, putrify in g animal 
matters, and certain products of morbid secretion, bring on grave 
disease of an adynamic or ataxic form, often complicated with 
gangrene, and most usually terminating fatally. Ergot, which 
produces gangrene of the tissues, must be classed, for this reason, 
with the septic, rather than with the narcotico-acrid poisons. 

D. There are but few determining causes among the excreta, 
the gesta or the percepta. A very abundant natural haemor- 
rhage, particularly if menstrual, may bring on anosmia. A strong 
muscular contraction may rupture a tendon, or break a bone : it 
is often the determining cause of hernia, and sometimes of dislo- 
cation. Very powerful moral affections, as disappointed love, or 
nostalgia in adults, and chagrin in children, are sometimes the de- 
termining causes of a species of hectic fever. A deep-seated pas- 
sion is commonly the determining cause of melancholy. Despair, 
terror, and immoderate joy, have, in some cases, caused sudden 
death. There are some diseases which may become the deter- 
mining cause of certain others. Thus, severe parotiditis has 
sometimes produced asphyxia ; a fracture or a dislocation, the 
formation of enormous abscesses in the cellular tissue ; perforation 
of the stomach, rupture of the gall-bladder, the urinary bladder, 
the uterus, the erosion of the intestines by ulceration, and of the 
pleura by softened tubercle, are so many direct causes of peritonitis 
or of pleurisy almost inevitably fatal. 

Retention of faecal matter in the rectum, has sometimes occa- 
sioned all the phenomena of intestinal occlusion, and in some rare 
cases has caused death, especially in aged patients. 

Finally, the presence of certain parasitic animals in the human 
body, may be added to the above determining causes, as taenia, 
the oxyuris, the ascaris lumbricoides, hydatids, etc. Their exist- 
ence does not always produce morbid phenomena, but is, in itself, 
something abnormal as regards the material disposition of the 
parts. Consequently, it constitutes a disease which will always 
be the same in its essence, however varied may be its form. It is 
the same with inanimate foreign bodies, introduced into our organs 
by the natural passages, or by the medium of a wound ; although 
their presence may occasion no disturbance of the health, we 
must, nevertheless, class them with the determining causes be- 



ETIOLOGY. 25 

because they act in a uniform manner ; the point of an instrument 
or a ball remaining in a wound, or a foreign body in the trachea, 
evidently belong to this class of causes. 

Specific determining Causes. The peculiar character of these, 
as was mentioned, is the production of diseases, which they 
alone can cause, and the impossibility of explaining them by 
physical or chemical laws. 

They are subdivided into two distinct series, according to their 
mode of action : to the first, belong those whose effects are confined 
to the individual who is exposed to their influence ; to the second, 
those morbific agents, which, like seeds, reproduce themselves in 
the course of diseases to which they give rise ; so that the indi- 
vidual affected by them, propagates them in turn, and may trans- 
mit them to other persons ; hence arises the necessity of sub- 
dividing specific causes into common and contagious. 

Common specific Causes. This series consists of certain me- 
tallic emanations, some of the poisons, miasmatic exhalations, 
and the venomous secretions of animals. 

Those who work in lead, painters, smelters of metals, those 
who grind colors or prepare the carbonate and red oxide of lead, 
etc., are subject to a disease known as lead colic, an affection, 
which differs sufficiently from all others to which the digestive 
tube is subject, to be ranked among the specific diseases. The 
colic caused by copper, on the contrary, closely resembles the 
inflammation resulting from external causes. Therefore, notwith- 
standing the similarity between these two kinds of colic, we must 
refer the action of copper upon the economy, to common determining 
causes, while the preparations of lead will come under the head 
of specific causes ; in like manner mercury and its compounds 
belong to this second series, in consequence of their entirely 
specific influence upon the mucous membrane of the mouth, 
{stomatitis, or mercurial salivation.} Strychnine and brucine, 
which cause tetanic convulsions, such as no other known sub- 
stance can produce, may with propriety be classed with the 
specific morbid agents. 

Miasmatic exhalations constitute another group of morbific 
causes, which reason would induce us to admit, but whose exist- 
ence even, has not, as yet, been confirmed by physics and chem- 
istry, much less their nature and effects determined. We shall 
refer them to two classes, according to their origin. 

The first spring from the decomposition of dead vegetable 
and animal matter, in moist or marshy places, and in stagnant 
water. These are styled marsh miasmata, the effluvia of 
marshy grounds : if it is borne in mind that intermittent fevers 
prevail habitually throughout the regions where the conditions 
which cause such decomposition exist; that these fevers make 
their appearance towards the end of summer, when the receding 
Avater has exposed its basin, formed chiefly by the remains of de- 
caying substances; if it be remembered that these affections have 
3 



26 



ETIOLOGY. 



always disappeared upon the drying up of the marshes ; that they 
show themselves only momentarily in most of those places where 
pools of water are accidently formed; if we notice that they are 
very frequent and exceedingly grave in the localities nearest to 
standing water, and become more rare and less severe in propor- 
tion as we remove farther from such places ; finally, if we regard 
the influence which the winds in the neighborhood of marshes 
have upon their development,* we cannot but admit the existence 
of these miasmata, and the part which they play in the produc- 
tion of intermittent fevers. Our authority for ranking the marsh 
miasmata among the specific causes, becomes the higher, from the 
fact that the specific character of the diseases which they produce, 
is demonstrated by the specific character of their remedy. There 
cannot be a specific remedy, except for those diseases which recog- 
nize one and the same cause. 

The other species of miasmatic exhalations is derived from liv- 
ing beings, healthy or otherwise, but chiefly from those diseased, 
when collected in too large numbers in confined places. 

The peculiar developing causes of infectious disease most often 
exist united, on board vessels, in prisons, camps, h6spitals, and be- 
sieged cities, and these are the conditions which cause a great 
number of diseases to rage with the most intensity; they have 
been described as putrid, malignant and pestilential affections. 
Almost all of them belong to the different kinds of typhus and to 
dysentery. 

By general agreement, they are deemed to be owing to the alter- 
ation of the air by the miasmata, and to the infection of the 
economy by it when thus vitiated ; by infection is understood the 
action exercised by these causes, and the resulting diseases are 
termed infectious. 

Venomous secretioyis must also be classed among the specific 
causes of disease. These are peculiar to certain species of ani- 
mals, and serve as their natural means of attack and defence : 
when deposited by the animal secreting them, in the wounds 
which it. inflicts, they occasion the same sort of affection in every 
instance. The viper, the wasp, and the bee, in our climate, are 
the only creatures provided with apparatus fitted for the secretion 
and deposition of these poisons. In warmer climates, the scor- 
pion and various kinds of serpents possess far more deleterious 
qualities. Venom differs from virus in many respects. The latter, 
as we shall hereafter see, is only produced accidentally, by diseased 
individuals; the formation of venom, on the contrary, is continual, 
and is not connected with any functional disturbance : virus acts 
slowly, and reproduces itself in those affections to which it gives 
rise ; the effects of venomous secretion are prompt, and not trans- 
mitted from the one who suffers by them, to others. 

§ II. Contagious Principles. There is a certain number of 
diseases which may be transmitted from the affected individual 

* Lancisi, Senac, AliberL 



ETIOLOGY. 27 

to healthy persons, who are in communication with him. This 
transmission of disease arising usually from direct or indirect 
contact, has been called contagion ; and the epithet contagious 
is applied to diseases thus transmitted. 

We are ignorant of the modus operandi of contagion ; neverthe- 
less it is probable that it takes place by means of a material agent 
whose existence cannot be called in question, although it escapes 
our perceptions : this agent is called the contagious principle or 
virus. 

Although not recognized by our senses, the contagious princi- 
ples have been made the object of special research by some phy- 
sicians. The following is the opinion of most pathologists upon 
this point. 

The invisible principle which causes contagion, is usually 
enveloped in a visible substance, as mucus, serous fluid, pus, 
(either liquid or dried into crusts.) and the matter of cutaneous 
transpiration. These different substances not being contagious in 
themselves, it is supposed that they do not become so, in certain 
cases, except by mixture with this subtle and unattainable matter, 
which is the agent of the contagion. At all events, it is not 
impossible that the pus and mucus may become contagious m 
themselves, by reason of the alteration effected in their essential 
nature. 

However this may be, the following are the chief characteristics 
of contagious principles : 

By means of a constant series of morbid phenomena, they all 
reproduce principles similar to themselves, and capable of causing 
the same effects. They maybe multiplied ad infinitum, by means 
of this secondary development, so long as they meet with bodies 
capable of fully receiving their action. Indeed, we doubt the ex- 
istence of any virus whose contagious properties become extinct 
after the second transmission, as some have endeavored to prove 
in regard to rabies ; nevertheless, we do not hesitate to admit that 
some kinds of virus, by continual reproduction, appear to become 
enfeebled 'in their action; for example, the syphilitic virus and 
that of the plague. 

Some of these contagious principles destroy, either temporarily 
or entirely, in the individual who experiences their effects, the 
susceptibility of being again affected ; such are those productive 

* Hufeland defines contagion, or the contagious principle, to be a subtle mat- 
ter which insinuates itself into the living body, and which may there excite a 
definite form of disease. The marsh miasmata are, according to him, and hy the 
above definition, contagious principles, as well as the variolous and syphilitic 
virus. He admits two sorts of contagion, the living and the dead. " The 
first is produced by a living body; it may occur in all those diseases where 
the humors have acquired a high degree of ■putridity, and when there is a 
specific change in the state of the secreting organs, as also in that of the 
humors which they secrete, as in measles, scarlatina, dysentery, etc. The 
other sort of contagion, is that derived from the exhalations of inanimate 
bodies ; such are the marsh miasmata, the foul air which causes catarrhal 
fevers, etc. 



28 



ETIOLOGY. 



of typhus, small-pox, scarlatina and measles : others have seemed 
to increase rather than diminish this liability to renewed attacks : 
the syphilitic virus is one of these. In other words, some conta- 
gious diseases attack the same person only once during life ; others, 
which are the exception, reappear at the end of some years; 
finally, others occur in those who have before been affected by 
them, more readily than in those who had previously escaped their 
effects. 

It is supposed that a certain proportion of the contagious princi- 
ples are produced without cessation during the entire course of the 
disease, while others only arise during a certain part of it; but this 
opinion is not yet sufficiently proved. 

The different modes of contagion have been likewise the object 
of particular research ; it may be immediate, or communicated by 
an intermediate body. 

Contagion is immediate when its principle is directly transmit- 
ted from the person who originates it to the one who receives it 
and experiences its effects ; this immediate transmission may occur 
in many ways : 1st, by remaining in the sick room when the air 
is charged with contagious principles, as appears to be the case in 
the transmission of typhus and perhaps of variola. 2d. By actual 
contact, as is observed in most diseases of this character. 3d. By 
still closer contact, as in the transmission of pestilential, vaccine 
and syphilitic virus, which are inert upon the sound skin, and 
cannot be communicated except the epidermis has been previously 
removed or destroyed, or the virus deposited upon a mucous mem- 
brane. 4th. Immediate communication, also, may be effected by 
means of the remains of animals destroyed by the disease which 
engenders the contagion : it is in this way that the malignant 
pustule is communicated to those who dress the skins, or handle 
the wool of such animals, &c. 

Mediate contagion arises through the agency of substances 
which have been in contact with the patient's body, as his clothes, 
and the various utensils employed about him. It has been remarked 
that among the substances which most readily receive and transmit 
contagion, woollen, silk, cotton and linen, hold the first rank ; a 
strong affinity for these materials has been ascribed to the conta- 
gious principles, which are retained by them a long while, espe- 
cially when kept from the air. Those holding communication 
with the sick may transmit contagion without being themselves af- 
fected ; and flying insects, alighting in turn upon the patients and 
upon healthy individuals, have been supposed to carry to the latter 
the virus which they had drawn from the former. 

The circumstances favoring contagion, or the action of contagious 
principles, have been carefully examined. It is considered highly 
important that the contagious principle be of recent origin ; its 
power diminishes gradually in the course of time ; for instance it 
has been proved by numerous experiments, that the pus of variola, 
after the lapse of a year, becomes less energetic, and at the end 
of three, is no longer contagious. Hildenbrand supposed that the 



ETIOLOGY. 29 

contagious principle of typhus did not exist beyond three months, 
because, according to him, no epidemic typhus is reproduced after 
that lapse of time, without the concurrence of new causes. 

Temperature also has a great influence in facilitating the trans- 
mission of contagious diseases ; the degree of heat peculiar to the 
human body seems most favorable to contagion, and the nearer the 
atmospheric temperature approaches this standard, the more easily 
are contagious diseases propagated. The sudden disappearance 
of pestilential disease when the temperature is below freezing, 
has led to the supposition that the contagious principle was 
susceptible of congelation. It has also been thought that these 
principles might be destroyed or burned, as it were, by extremely 
elevated temperature; arid those physicians who enumerate yellow 
fever among the contagious diseases, have supported the theory of 
the decomposition of virus by heat, by the fact of the sudden cessa- 
tion of that disease in the torrid zone, when the atmospheric heat 
attains an unusual degree of intensity. M. Bulard has observed 
the same in regard to the plague of the East. The frequency of 
typhus in winter and its greater violence at that season, seem to 
invalidate the assertion that we have lately made, viz., that a tem- 
perature approaching that of the human body would be the most 
favorable for the transmission of contagious diseases. But if we 
reflect that the number of sick soldiers is much greater during 
winter campaigns, and that the cold weather renders it indispensa- 
ble to quarter them in places partially or entirely closed, where in 
a short time they become crowded, we shall understand that if epi- 
demic typhus is more frequent and destructive in cold and wet 
seasons, it is not owing to the cold, but to the concurrence of those 
injurious circumstances which have just been mentioned. Still 
farther, it has been remarked that dampness, absence of light, and 
animal emanations favor the transmission of contagious disease. 

Besides these general circumstances which assist the action of 
contagious principles, there is a certain number which are peculiar, 
and which exercise the same influence ; such are youth and adult 
age, an impressible and delicate constitution, want of food, absti- 
nence from alcoholic drinks in persons who have habitually used 
them ; the weakness accompanying convalescence, fear, discour- 
agement, terror, errors in diet, excessive evacuations, and the state 
of sleep. 

Man is. almost constantly, the source which begets and perpetu- 
ates the greater part of the contagious principles with which we 
are acquainted. There are, however, some which seem not to be 
spontaneously developed in him, but to be always transmitted by 
animals; such are rabies, glanders, and the vaccine disease. 

Among contagious diseases, or those considered as such, there 

are several which originated upon this continent, typhus fever and 

the itch are examples ; there are others which have been imported ; 

variola, scarlatina and measles originated apparently in Asia ; the 

3* 



30 ETIOLOGY. 

plague, in Asia or Africa ; syphilis and yellow fever were proba- 
bly brought among us from America.* 

The primitive formation or ge)ieration of contagious principles 
is shrouded in great obscurity. Some physicians think that having 
been generated at one particular time, they have ever since been 
reproduced by means of transmission only. This opinion is, 
however, inadmissible. It is true that the conditions under which 
many of these principles are developed, are unknown ; but still 
we must allow that they can, and must be, reproduced by a con- 
currence of causes resembling those which first brought them into 
being. The history of European typhus, and its reproduction 
under the action of well known circumstances, exemplify this 
opinion, and lead us to suppose that there must be some analogy 
in the development of exotic poisons, as those of the plague, 
variola and syphilis. 

But if, as everything would induce us to think, these different 
sorts of virus did not originate in Europe, if they were first 

* Were not the incompatibility of this assertion with the date of the first appear- 
ance of syphilis, in Europe, sufficient to prevent its incorporation into the present 
work, even in the slightly qualified terms used by the author, it would seem that 
the concurrent testimony of the best authorities of more remote times as well as of 
our own, would have rendered its insertion impossible. Jourdan, long since, suf- 
ficiently disproved the opinion of the American origin of syphilis, and by an elabo- 
rate comparison of dates showed the utter impossibility of its having been imported 
into Europe, according to our author's supposition. But it is unnecessary to re- 
peat his widely known observations, or even the apparently well-founded opinions 
of many others who date the origin of the disease as far back as the days of Old 
Testament narration ; among these are B. Bell and M. Cazenave, cited by Grisolle 
in his late work upon Internal Pathology, 1 who himself also, although heconsiders 
the question undecided, evidently leans toward the ancient origin of the disease, 
and mentions a statute of Jeanne the First, Queen of the Sicilies, relative to medi- 
cal inspection of prostitutes diseased in their genital organs ; this was in 1347, — 
and no author has pretended that the disease was imported before the arrival of 
Columbus and his companions from America in 1493. Oviedo, one of the cham- 
pions of the importation doctrine, mentions its appearance in America in 1498, 
which is after its manifestation at the siege of Naples, by Charles VIII., the con- 
quest of which city was effected in 1195. Some have asserted its existence at 
Paris, in 1494. It is likewise stated to have been " raging " at Rome, and in 
other parts of Italy in June, 1493, and even supposing the possibility of its having 
been carried to that country by the followers of Columbus, who arrived from 
America only two months previously to the latter date, is it reasonable to suppose 
that it could have been raging in various parts of the country so soon ? Besides 
the importation by these men in that space of time, is not proved. Hunter, Spren- 
gel, Pearson and Bacot, among others, have lent the powerful influence 'of their 
names and arguments against this doctrine. M. Cazenave, of all modern writers 
perhaps, uses the strongest language, and furnishes the most irresistible proof in re- 
gard to what he considers the "fable " of the American origin of syphilis. Some 
account of his views may be found in the British and Foreign Medical Review for 
April, 1817, pp. 346, 347. Why is it not reasonable to suppose that promiscuous 
copulation in any country and among the most cleanly people, might engender disease 
of the genital organs 1 But was it less likely to occur among the dirty dnd depraved 
soldiers of a European army, and the luxurious profligates of the higher classes 
than among the inhabitants of America, simple in their habits, and, as It were" only 
on the borders of civilization ? — Trans. ' 

1 Path. Int., vol. ii. p. 23. De La Syphilis ou JIaladie Venerienne. 



ETIOLOGY. 31 

generated in other countries and with an assemblage of conditions 
nonexistent among us, we must suppose, whenever we observe 
them, that they are owing to contagion, even when we cannot point 
out the individual from whom it emanated. 

Among exotic poisons, many are acclimated on our con- 
tinent ; they appear there without interruption, and produce at 
intervals, (doubtless with the concurrence of favorable atmospheric 
conditions,) epidemics of greater or less severity : variolic virus 
and that of scarlatina and measles, are examples. Other conta- 
gious diseases, or those so reputed, as the plague and yellow fever, 
manifest themselves, as it were, only momentarily : they usually 
disappear, after having committed their ravages for some seasons. 

Linnceus published, in the Amenites Academiqucs, a dissertation 
wherein he endeavors to establish that all contagious diseases are 
owing to animalcules, which, by being transported from the infect- 
ed to the healthy, transmit the disease, which is but the effect of 
their presence. The foundation of this theory may be seen in the 
work above mentioned ; some very curious details, especially, will 
be found, relative to the form and habits of the acarus dysen- 
terice, but these are foreign to our purpose. The interesting 
researches which have since been made, have firmly established 
this opinion, as regards the itch; the existence of the acarus scabiei, 
is now demonstrated ; but there is no reason for supposing any- 
thing analogous in other contagious diseases. 

Such are the chief morbific causes, which, brought into action 
upon the economy, invariably produce the same effects. Their 
mode of action will be hereafter considered. 



ARTICLE SECOND. 
Predisposing Causes. 

According to the course generally agreed upon in the methodical 
study of all sciences, we have thought proper to speak first of the 
most apparent causes of disease ; at present, we intend to examine 
those which are the least so, commencing with those called pre- 
disposing, which, as we have said, act by degrees upon the econ- 
omy and prepare it for various affections. Their action is almost 
always obscure and often questionable. All that we shall say 
therefore, upon this action, must be considered as a collection of 
generally admitted opinions on the subject, rather than the con- 
sequence of facts rigorously observed, or the expression of our 
own conviction. 

Some of the predisposing causes extend their action to a great 
number of individuals at once, as to the entire population of 
a city, a province or an empire; sometimes to large collections 
of men encamped, or in navies, hospitals and prisons ; they favor 
the development of similar, or analogous affections in all who are 



32 



ETIOLOGY. 



exposed to their influence : we shall style these, general predis- 
posing causes. Others act only upon isolated individuals: these 
may be called individual predisposing causes. The principal 
morbific causes belonging to these two series, will now be briefly 
enumerated. 



SECTION FIRST. 
General Predisposing Causes. 

The general predisposing causes are, for the most part, diffused 
in the atmosphere, or arise from certain local conditions. 

Atmosphere. The air has a very decided influence upon the 
human body: this is, however, limited, and it does not at all follow 
that the state of the economy should be entirely subordinate to 
that of the atmosphere, as some physicians have pretended.* 

The frequent changes of the atmosphere are occasional rather 
than predisposing causes of disease. It is more particularly, when 
for a long time in the same state, that the air seems to produce modi- 
fications in the human body, from which result various predispo- 
sitions to disease. A cold and dry air predisposes to deep-seated 
inflammations, and active haemorrhage, and gives to the greater 
part of acute affections which may be developed, their character, or 
what has been called inflammatory nature. A warm and dry air 
hastens the development of superficial inflammations, as erysipe- 
las, and the exanthemata, and often gives to acute disease the 
form termed bilious. Affections of the mucous membranes and 
those called adynamic, prevail under the influence of a warm and 
moist air: catarrh, scurvy and rheumatism occur more particularly 
when the atmosphere has for a long while been moist and cold. 

In our climate,! the north and east winds are almost always 
dry and cold; the south-east dry and warm; the south-west is 
of a warm and moist temperature ; the north-west is cold and 
moist. The influence of these winds in the production of dis- 
eases is the same as that of the different qualities to which they 
correspond. 

Air which is not renewed, quickly becomes vitiated, as may be 
remarked in confined apartments, especially in dungeons and 
subterranean passages. Man cannot remain long in such places 
without experiencing injurious effects ; his functions languish, his 

* Talis est sanguinis dispositio, quails est aer quern inspiramus. — Ramazzini 
de Constitutions, anni 1691. 

f The reader will of course perceive the necessity of adapting the above 
remarks in regard to the influence of the winds, to " our climate ;" our differ- 
ent position, as respects the ocean, changing wholly the nature of that influence : 
as for instance, the north and east winds with us, are almost uniformly moist 
and cold : the term "dry" is almost never applicable to our south-east wind 
although it may, sometimes, be " warm ; " our south-west winds are warm and' 
dry, and our north-west, cold and dry. — Trans. 



ETIOLOGY. 33 

constitution becomes enfeebled, and chronic affections of different 
kinds are developed. The stagnation of the air in the ravines 
of the Valais, appears (from the researches of Fodere) to be the 
principal cause of the frequency of goitre in that country. 

Considerable variations in atmospheric pressure may also be 
considered as causes of disease. Examples are cited of ocular 
haemorrhage, of epistaxis and haemoptysis determined by a dimi- 
nution of the weight of the air, produced either by a change 
supervening in the atmosphere, or because the individual, being 
elevated into a higher region, was submitted to the pressure of a 
smaller column of air. The diminution and increase of atmos- 
pheric pressure have also been declared equally powerful causes 
of cerebral congestion and apoplexy. 

Deprivation of light disposes to anasarca, to scurvy and scrofu- 
la, and always gives rise to a sort of etiolation, similar to that 
produced by the same cause in vegetables. 

The researches of M. Edwards also go to prove that the action 
of light is necessary for the development of the body, and that 
its withdrawal may be considered one of the external causes 
productive of deformity in scrofulous children.* This agrees also 
with the generally admitted opinions upon the etiology of these 
affections. Hildenbrand has likewise remarked that absence of 
light greatly favored the contagion of typhus. f 

Does electricity diffused in the atmosphere, aid in developing 
disease, as some modern physiologists have asserted? Can we 
admit the existence of a nervous fluid analogous to galvanism ? 
Does it follow that vital power is increased when positive elec- 
tricity is in excess ; that it diminishes when negative electricity 
is most abundant, in low and moist localities, before storms, in 
warm seasons, and with a west wind 1 These purely hypotheti- 
cal opinions are not suitable for present discussion. 

As Hippocrates remarks, all diseases may manifest themselves 
at any time of the year ; nevertheless, the natural changes which 
supervene in the atmosphere, by reason of the succession of sea- 
sons, influence very powerfully the development of many among 
them. This influence, which has been recognized from the 
earliest days of the science, has been confirmed by physicians of 
every age. Hippocrates remarked a uniform character among 
summer diseases ; he likewise noticed some analogy among those 
of winter,J and he comprised among the former, the complaints 
common in the latter half of spring and the first half of autumn ; 
and in the second class, those of the last of autumn and of the 
early spring. In our climate, more resemblance exists between 
the diseases of spring and of the months preceding and following 
that season, than between those of summer and the neighboring 

* Influence des Agens Physiques, pp. 401 et 402. 
| Ti/ph. conta. 
J Aphor. lib. iii. 



34 ETIOLOGY. 

months; the same observation applies to the complaints of 
autumn and winter, and those of spring and autumn form sepa- 
rate groups. The progress of the former is more rapid, their ter- 
mination more complete, their duration less ; in them, relapse is 
not so common, and remedies are more efficacious. The develop- 
ment of the other class is more gradual, their continuance far 
longer, and sequelae of a bad and obstinate nature often succeed 
them ; they do not yield as readily to treatment, and are more 
easily reproduced after momentary suspension. This difference 
has been particularly observed in intermittent fevers, vernal or 
autumnal ; but it is by no means a rule of constant application. 
In our climate, the number of grave diseases is uniformly more 
considerable, and the mortality greater, in spring than in au- 
tumn. 

In addition to the above marked differences which these two 
opposite periods of the year cause in disease, it has been observed 
that each season has, in like manner, a less noticeable, but still an 
incontestible influence.* 

Winter, with a dry atmosphere, usually predisposes to inflam- 
matory complaints, active haemorrhages and cerebral congestions ; 
when wet, to affections of the mucous membranes and chronic 
discharges. In summer, bilious diseases, cutaneous exanthemata, 
cholera morbus, mental alienation and various other neuroses, 
prevail. Autumn apparently contributes to the development of 
mucous and rheumatic affections, dysentery and intermittent fe- 
vers, which are more frequent at this season than at any other. 
Spring almost always abounds in inflammations of the throat and 
chest, and in haemorrhages, etc. 

The influence of the moon, and fixed stars, upon the develop- 
ment of disease has often furnished physicians with matter for dis- 
cussion. If these bodies exert no action upon the temperature and 
moisture of the air, it is very likely that they have none upon the 
animal economy. But if, as many natural philosophers have as- 
serted, tides, storms and the course of the winds are subject to the 
influence of lunar changes, the moon might possibly have a direct 
action upon the economy ; an indirect effect might, at least, be 
demonstrated. 

Localities. There is no part of the earth which is not habitable 
by man. But although capable of inhabiting every place, he can- 
not escape the influence which is thus exerted upon his constitution 
or the morbid modifications communicated. In southern climates, 

* Some physicians, supposing they had observed that the principal changes 
caused by the seasons in prevailing diseases, did not correspond exactly to 
the divisions of the common year, proposed to form a mtdical year, in which 
spring should commence on the twelfth of February ; summer on the twelfth 
of May ; autumn in August, and winter in November ; but, as there is no regu- 
larity in the period when the so-called vernal or autumnal diseases appear, 
as their manifestation even, is not constant, it is more reasonable to continue 
the usual ljmits to each great division of the year, and to the words in common 
use their general acceptation. 



ETIOLOGY. 35 

tetanus, yellow fever, and many diseases wholly unknown at the 
north, prevail ; in the opposite latitudes, inflammatory affections 
are very frequent : in temperate climes a greater variety of disease 
exists. In dry and elevated districts, men are exceedingly subject 
to all the acute affections ; chronic complaints, on the contrary, pre- 
vail in low and wet countries. This influence of elevated position 
may be easily verified in cities built both on high and low ground ; 
in the upper portion, diseases are rare and of very rapid progress ; 
in the lower, they are more frequent and tend to the chronic type. 

A northern or eastern exposure, or a southern or western one 
have the same influence in the development of disease, as the 
winds blowing from either of these directions. (Page 32.) 

City and country life dispose to very different affections. The 
neuroses, scrofula, rachitis and pulmonary phthisis are far more 
frequent among the inhabitants of cities than among those residing 
in the country ; a country population is more exposed to acute dis- 
ease, and chronic affections are rare. A residence in hospitals, 
prisons, vessels, and barracks apparently predisposes to dysentery, 
scurvy and different kinds of dropsy. 

Change of abode likewise becomes a general predisposing cause 
for sailors and soldiers transported far from their country. Lind 
compares men who have left the land of their birth to vegetables 
transplanted into a strange soil ; they cannot experience the new 
conditions in which they are placed, without injury to their health 
or a loss of vigor, at least for a time. The masses of men which 
are transported far from their country, the European troops which 
go to another continent, are often smitten by more or less severe 
disease, evidently owing to this cause ; for these diseases not being 
known in the country where the men were born, they would have 
escaped them if they had remained there ; of such is the yellow 
fever which destroys Europeans in some parts of America, and 
which has never been observed in the north of Europe, above the 
mouth of the Gironde ; and abscess of the liver, so rare among us 
and so common in some parts of India. 

An almost constant fact, to which the attention of physicians 
has not, perhaps, been sufficiently directed, is the good health on 
board fleets which traverse the seas without making any port, and 
which is singularly in contrast with the diseases that afflict 
them under opposite circumstances. The constant change of 
place seems useful to man upon the ocean, as well as on land ; 
voyages generally preserve and strengthen the health; if pas- 
sengers become diseased, it is almost always when they have been 
stationary for a certain time in the same place. 

The changes brought about in certain situations through the 
agency of man, as the clearing of forests, or the cutting of canals, 
have sometimes produced a marked effect upon the sanatory con- 
dition of the population. 

There are still some predisposing causes of disease, which may 
act simultaneously upon a great number of individuals, and which 
at present we shall only mention, because they act most com- 



36 ETIOLOGY. 

monly upon isolated individuals, and thus appertain more naturally 
to the individual predisposing causes. Such are clothing, food 
and the moral affections. 

Wet garments suffered to remain upon the body, are one of the 
chief causes of rheumatism and dysentery in land armies, and of 
scurvy on board ship. If it surprise us that a cause, to all appear- 
ance the same, should produce different effects on land, and at sea, 
the reason of this difference may be discovered in the opposite 
qualities of rain and sea-water, the latter of which contains deli- 
quescent salts, which prevent the complete drying of the sailor's 
garments and keep him constantly wet. 

Food which has become putrid, salted meat, want of flour, or 
of fresh vegetables, and bad water, are all general causes of disease 
for the inhabitants of a besieged city, or for men in large num- 
bers on board a fleet or in camp. 

The moral affections, which are the same for the whole of an 
army, and sometimes for all the inhabitants of a city, or an empire, 
may be considered in some cases general predisposing causes. The 
influence of these affections upon the health of our soldiers, in the 
disastrous campaigns of 1813 and 1814, was very evident ; the 
number of diseases increased in a frightful degree, as fortune for- 
sook our banners. 

Political institutions, and the more or less advanced state 
of civilization of different nations, must also be ranked in the 
number of the general predisposing causes of many diseases ; it is 
for this reason that in free countries, among enlightened people, 
where the intellectual faculties are most active, where man de- 
votes himself to the study of the sciences and arts, to commercial 
speculations and to labor, and among nations often distracted by 
violent political commotions, mental alienation and hypochondria- 
sis are far more frequent than where the people live in idleness, 
ignorance or slavery. 



SECTION SECOND. 
Individual Predisposing Causes. 

Individual predisposing causes are much more numerous than 
those termed general, because there are many circumstances 
which may act upon isolated individuals and cannot be common 
to a great number ; while all the general predisposing causes, as 
situation, dwelling, etc., are also individual predisposing causes. 

These causes being very numerous, and their influence in pro- 
ducing disease not being the same, we shall divide them into two 
series. In the first, will be classed the various conditions peculiar 
to each individual, as birth, age, sex, temperament, constitution 
habits, profession, degree of comfort or privation, illness, conva- 
lescence, health, and pregnancy ; and we shall designate these 



ETIOLOGY. 37 

different conditions by the term aptitudes, since they dispose the 
individuals to various diseases, rather than take an active part in 
their production. * 

In the second series will be enumerated those various external 
circumstances, which predispose with more or less energy to the 
development of disease. 

I. Aptitudes. 

A. A descent from parents affected with certain diseases, is a 
condition which should lead us to fear the development of similar 
affections. " The ailments of our parents," said Baillou, " are 
inherited as well as their goods, and this sad inheritance is far 
more certainly transmitted than the other." Diseases which thus 
pass from father to child, are called hereditary, ; sometimes, so to 
speak, they skip one generation and manifest themselves in the 
grandchildren. They may appear in every child ; but usually, only 
in a limited number. They may be transmitted by either father 
or mother. Cullen has observed that children are most subject to 
the diseases of the parent whom they most resemble. 

The diseases of the mother are perhaps more commonly trans- 
mitted than those of the father, not only because there is certainty 
in regard to the maternity, but also because the female, whose 
part in the act of conception is equal to that of the male, supplies 
from herself alone, what is required for the development of the 
foetus during its entire intra-uterine existence, and also nourishes 
it from her own substance through the whole period of nursing. 
It is, therefore, natural to suppose that the mother has a greater 
influence than the father upon the child's constitution, and upon 
its predisposition to disease. In support of this opinion, let 
it be remembered that in the crossing of animals, the relative 
influence of the two sexes is quite manifest : the mule, which is 
the issue of the mare and the ass, is incomparably larger and 
stronger than the product of an opposite cross. 

There is no longer any dispute in regard to the transmission of 
diseases from parents to children, considered in an abstract manner: 
but admitting this first point, discussions arise with regard to the 
question of the hereditary nature of particular diseases. There 
could be no doubt on this point, if the affections were such as show 
themselves only in the offspring of those who had suffered by 
them, and if all the children of parents so affected were attacked 
without exception ; but this is not the case. On the one hand, 
every disease susceptible of transmission from parents to children 
may occur from other causes, and on the other, there is no cause 
which uniformly affects all the children who become diseased; 
it is only by aid of exact and numerous observations, which sci- 
ence does not yet possess, and which it can only slowly acquire, 
that we shall be able to appreciate the relative frequency of a dis- 
ease in individuals born of affected parents, and in those whose 
4 



38 



ETIOLOGY. 



parents have been exempt from it, and thus determine how far 
a disease is hereditary. 

When we wish thus to study any disease, phthisis, for in- 
stance, we must seek the solution of the problem more by follow- 
ing the course of the children's lives, who are born of parents 
destroyed by this disease, than by going back to the complaints 
of which the parents died. It is, indeed, needless to examine 
whether the disease may be developed or not by the aid of 
hereditary predisposition and occasional causes. This is not the 
question : no author has asserted that a disease susceptible of 
transmission from father to child could not be developed likewise 
by other causes. The real question is, to determine at first, if such 
a disease is transmitted from parents to children, and afterwards, 
how frequently this happens. It is then, by following the gener- 
ations, rather than by tracing them back, (if we may be allowed 
the expression,) that the question of hereditary disease must be 
studied and definitely decided. We are convinced that by follow- 
ing this course in regard to pulmonary phthisis, results will be 
obtained, proving that children born of phthisical parents, die, in 
a great proportion of cases, of the same disease. It is not so easy 
to say what would be the result of similar research with the 
intention of ascertaining whether cancer is hereditary. In the 
present state of science, it appears to us reasonable to allow, 
without however affirming it, that individuals born of cancerous 
parents, are, other things being equal, more often affected with 
like complaints than those who are not thus connected. 

In general, diseases which are developed under the influence 
of hereditary predisposition, are manifested at an earlier age than 
when not thus transmitted. It has been remarked, that children 
born of consumptive parents, died at a less advanced age than 
their parents, and often before they were old enough to transmit 
this unfortunate predisposition. 

Reputed hereditary affections are exceedingly various. Some 
consist in an evidently vicious conformation, for instance, a 
diminution or increase in the number of organs ; others, in simple 
functional disturbance without any appreciable lesion of the 
tissues, as blindness or deafness. Some are congenital, as is 
occasionally the case with syphilis, etc. ; others, and by far the 
greater number, are latent for a longer or shorter time after birth ; 
rachitis until the second or third year; scrofula and epilepsy 
appear in infancy; pulmonary consumption and mental alienation 
in youth ; gout and haemorrhoids in adult age ; apoplexy still 
later. In some families hereditary disease is developed and ter- 
minated, uniformly at the same period of life. Montaigne, whose 
ancestors were affected with gravel, was attacked by it at the 
same age as his father. Some practitioners have thought that 
chronic affections only, could be transmitted from parents to chil- 
dren; and it should be remembered that phthisis, mania and 
epilepsy occupy the first rank among hereditary diseases. Gout 
and rheumatism, however, are usually, acute diseases, at any rate 



ETIOLOGY. 39 

in their first attacks, and by common consent, are hereditary. In 
some families it has also been observed that there exists a 
tendency to plethora and to certain inflammations. 

The diseases which infants exhibit at birth, {maladies de 
naissance,) are not always hereditary; those affected with hydro- 
cephalus or spina bifida, die soon; they cannot, consequently, 
transmit these diseases, and for the same reason they cannot have 
inherited them. Still farther, it has been remarked in certain 
cases, that all the children, or most of them, have been attacked 
by disease with which their parents never had been or could be 
affected ; among other instances is sterility, noticed in all the 
daughters born of the same parents. Squamous disease of the 
skin and scrofula appear sometimes in all the children born of the 
same 'parents, although they may never have had those diseases. 
We must then, with Portal, admit family diseases, vfh\ch although 
never observed in father or mother, but declaring themselves in all 
their children, are evidently ascribable to the influence exercised 
in generation by the concurrence of two determinate organizations, 
which give rise to one ditfering from each of the others, the 
same thing happening in all the offspring of such connection. 

We shall not give a detailed account of the different theories 
which relate to the hereditary transmission of disease. Like ex- 
ternal characteristics, this transmission is a well marked phenom- 
enon, but quite as inexplicable. The various hypotheses on this 
subject may be seen in the little work of Meara. * The Consider- 
ations of Portal upon hereditary and family diseases will be read 
with much greater interest by those who prefer facts to explana- 
tions : in this work the learned author has collected all that is 
useful and curious upon this point in pathology. \ 

B. Age. This is not, properly speaking, a morbific cause. 
No period of life plays an active part in the production of disease, 
but there is greater liability to certain affections at some ages than 
at others. Some complaints never appear previous to or after a 
certain period; on this account, those aptitudes for contracting 
disease which belong to the different ages, possess a peculiar 
interest for the student. 

Many affections may be developed at all periods of our existence, 
from intra-uterine life to the most advanced age. Children have 
been born with intermittent fever and with variolic eruption, both 
of which may occur at any other age. There are, however, 
diseases peculiar to every age, or at any rate of more frequent 
occurrence during such periods. Hydrocephalus and spina bifida 
are developed while the foetus is yet in utero. The diseases 
most frequently noticed at birth are the asphyxia of the new-born, 

* Pathologia hereditaria generalis, sive de morbis hereditariis tractatus, spa- 
gyricodogmaticus. — (Authore, Derm. Meara ; Dublin 1619.) 

+ Considerations sur la Nature et le Traitement des Maladies de Famille et des 
Maladies hereditaires, par Antoine Portal. 1814. Paris. 



40 ETIOLOGY. 

icterus and hardening of the cellular tissue. From the first to 
the seventh year, the child is chiefly exposed to the eruptive 
fevers, to the accidents of dentition, epistaxis, croup, whooping- 
cough, tinea, rachitis, scrofulous complaints, acute hydrocephalus, 
tubercular meningitis and verminous affections. The period of 
puberty in females is fraught with various diseases. In both 
sexes, rapidity of growth sometimes disposes the system to 
serious affections. Plethora, inflammatory disease, haemoptysis, 
angina and pulmonary consumption are more frequent in youth 
than at any other age. In middle life, hypochondriasis, haemor- 
rhoids, cancer and the greater portion of organic diseases occur, 
scrofula excepted. In old age, softening and haemorrhage of the 
brain, idiocy, deafness, cataract, affections of the urinary passages, 
etc., are more common than in earlier life. 

The etiological study of the different ages offers still another 
consideration, viz. the inaptitude of certain ages for developing 
certain diseases. Thus cerebral haemorrhage is hardly ever ob- 
served before middle life; nor scirrhus and arterial aneurism 
previous to the thirtieth year; typhoid fever has perhaps never 
been observed after the age of fifty -five. These data are occasion- 
ally very useful in diagnosis. 

C. The ancients supposed there were certain fixed years in 
human life, when diseases were more frequently developed and 
attended with greater mortality. They called them climacteric 
years, from the word xVtua, tendency, or from y.v^at, signifying a 
scale or degrees. They compared these years to knots, which 
might be said to unite the different periods of life, and to give a 
new direction to the economy. This doctrine, which is said to have 
been derived by Pythagoras from the Chaldean institutions, was for 
a long time in great favor in the schools. Nearly all who have ad- 
mitted the climacteric years, have fixed them at intervals of seven 
years ; they asserted the fourteenth and twenty-first years to be 
replete with danger. Others have divided them into periods of nine 
years. Some mingled the two, and the sixty-third year, composed 
of the numbers seven and nine, was, in their estimation, the most 
fruitful in diseases, especially those of fatal termination. Others 
preferred a triennial interval. All of them supposed that the space 
of time they thus allotted, was requisite for the complete renovation 
of the constituent elements of the body ; so that at the end of three, 
seven and nine years, there did not remain in the system any of 
those parts which previously composed it; and, admitting this 
entire change in the constitution, an analogous change in the 
health seemed to them the almost unavoidable consequence. It is 
very certain, that in an indefinite time, varying according to age 
and many other circumstances, the body is renewed, and that 
hardly any of its former constituent parts are then found in it ■ 
but this change is not a sudden one : it is continuous, and modifies 
unceasingly the component parts of the body. It is no more per- 
ceptible at the seventh or ninth year, than upon every day which 



ETIOLOGY. 41 

goes to make up the climacteric periods. These useless specula- 
tions have, with great reason, been rejected; they seem fitted 
merely to torment the imagination of the sick. * 

D. The sexes are nearly alike in their predisposition to most 
diseases : fevers, inflammations, nervous and organic affections, 
attack males and females without distinction. If there be any 
difference between their diseases, it is rather to be attributed to 
the mode of life, than to sex. If the male be more subject to 
wounds, contusions, fractures, rheumatic affections and typhus, it 
is because he is more exposed to the causes of such affections. In 
like manner, in cities, women are more subject to nervous diseases 
than men. But in the opposite case ; if we compare the female 
who labors in the fields, to the man who leads a luxurious and 
inactive life in the city, the former will be observed to be liable to 
the same complaints as the man whose occupations are similar, 
and the latter to all those nervous affections which have been con- 
sidered as peculiar to females. There are, indeed, certain diseases 
which attack one or other of the sexes most frequently ; of these, 
tuberculous disease of the lungs is more common in females than 
males; and that this difference is observable in every period of life, 
any one may be convinced by consulting the statistics of M. M. 
Louis, Benoiston de Chateauneuf and Papavoine. 

There are certain diseases which almost exclusively belong to 
sex : not to mention those of the genital organs and their appen- 
dages, as hydrocele and sarcocele in man, scirrhus and inflamma- 
tion of the uterus and ovaries in the female, stone in the bladder 
and retention of urine are almost exclusively confined to the male 
sex, while crural hernia, hysteria and mammary cancer are pecu- 
liar to women. 

E. Temperament predisposes to various affections, and gives a 
peculiar character to any that may be developed. In the san- 
guine temperament, there is a tendency to plethora, to deep-seated 
inflammation, haemorrhages, etc. ; and almost all the acute dis- 
eases occurring in persons thus constituted, are accompanied 
with general symptoms of inflammatory fever. The bilious tem- 
perament is conducive of bilious diarrhoea, the exanthemata, 
inflammations of the membranes and organic disease, especially 
cancerous degeneration. Those of a lymphatic temperament are 
peculiarly liable to catarrh, chronic discharges, dropsy, scrofula, 
and scurvy ; and nearly all the acute diseases which affect them are 
of an adynamic character, and slow in their progress. Those of a 
nervous temperament are particularly subject to hysteria, hypochon- 

* Some authors have given a different signification to the vi or A climacteric : 
they understand by it the periods of life at which great changes occur, indepen- 
dently of the numerical order of the years; such is the epoch of puberty in botli 
sexes and the suspension of the menstrual discharge, or critical season, in females. 
Every one allows the influence of these climacteric cpocJis upon the constitution 
and health. 

4# 



42 



ETIOLOGY. 



driasis, convulsions, disturbance of the sensations and intellectual 
faculties, melancholy, mania, etc. ; and in addition to the ordinary- 
symptoms of acute disease, various disorders of innervation, which 
alter the character of the affection, make its course irregular and 
its termination less certain. The mixed temperaments predispose, 
though less energetically, to the affections peculiar to each of the 
temperaments united in the same individual. 

F. A very strong constitution seems rather a preservative 
against all disease than a predisposant to any. Nevertheless, it 
has been observed that such constitutions are more subject than 
others to acute and violent inflammatory affections. Those of 
feeble constitution, on the contrary, are liable to frequent and slight 
attacks of disease, and to habitual indisposition, and nearly all of 
them die of chronic disease. It has also been remarked, but with- 
out sufficiently accurate data, that very corpulent persons are 
subject to apoplexy, and are almost entirely exempt from inflam- 
mations of the thoracic organs. * 

The disposition of each part of the body seems also to have an 
influence in hastening the development of disease. Considerable 
volume of the head should lead us to apprehend hydrocephalus in 
children and apoplexy in the aged. A remarkably broad chest 
excites suspicion that the contained organs have a size dispropor- 
tioned to that of the other viscera, and this disposition is like the 
first stage of cardiac aneurism. Those in whom all the cavities 
are large, or to use the expression of Hippocrates, who have volumi- 
nous viscera, are, according to this prince of medicine, liable to 
arthritis. The weakness of the aponeuroses which correspond to 
the natural apertures of the abdomen, is the chief predisposing 
cause of hernia. The structure of the bones in children, favors 
the detachment of their epiphyses and their abnormal curvature ; 
in the adult, the angles which the neck of the femur forms with 
its supporting bone, and the ramus of the lower jaw with its 
body, favor the fracture of the one and the dislocation of the 
other. Finally, in the aged subject, the diminished thickness of 
the compact part of the bones, the predominance of their inorganic 
element, and the increased size of the medullary cavity of the 
long bones, are each circumstances explanatory of the frequency 
of fracture in old age. 

G. Habits, which arise from the frequent repetition of the same 
acts in a given time, are usually injurious to those who become 
enslaved by them, and they are very properly numbered among 

* Obesa corpora minus pleuritidi et peripneumonia sunt obnoxia, ut animad- 
verlit aeque diligens ac eruditus medicus Trillerus. Quod cum omnes peripneu- 
momcos a me visos aut curatos memoria repeto, verum esse intelligo ; et ipse 
poteris, perlectis eorum qui a Valsalva itemque & me dissecti fuerunt historiis 
cunctis, duobus exceptis, facile cognoscere. (Morgagni de Sed. et Caus. morb., 
Epist. XX. art. 10.) 



ETIOLOGY. 43 

the predisposing causes of disease. The power of habit and the 
danger of its discontinuance are in proportion to its duration and 
the number of actions committed under its influence in a given 
time. So great is this power that, as Cabanis has remarked, it 
would be dangerous to change from the worst regimen to the 
wisest and best. Now as there is no habit which we can be sure 
of satisfying through life, it is prudent not be bound by any, unless 
absolutely compelled. Many habits are injurious to the health 
from the moment they are contracted ; all may become so if 
interrupted. 

H. The professions may predispose to different diseases, by the 
concurrence of circumstances in which those practising them are 
placed. Literary men are subject to headaches, wakefulness, and 
haemorrhoids ; many die of apoplexy. Faggot-bearers are subject 
to hernia ; watermen, to a peculiar alteration of the dermis, charac- 
terized by softening, fissures, and frequently absorption of the parts 
in contact with the water ; * while, contrary to the common opin- 
ion, they are rarely affected with ulcers of the legs ; f varicocele 
is of frequent occurrence in horsemen. 

I. Statistics collected by numerous distinguished physicians, 
demonstrate satisfactorily the sad influence of poverty upon mor- 
tality. Dr. Villerme has proved by very interesting researches, 
that in Paris and many other large cities, the proportion of deaths 
to the number of inhabitants in the different quarters, is in an 
inverse ratio to their degree of comfort. % M. Benoiston of Cha- 
teauneuf has arrived at similar conclusions ; he has observed that, 
at the same periods of life, the mortality among the poor is almost 
double that of the rich. |j The diseases most usually observed 
under these circumstances among the poor are scurvy, scrofula, 
tinea and some other exanthematous diseases; in the higher 
classes, inflammatory and nervous diseases are most frequent. 

It nevertheless sometimes happens that similar affections, not 
contagious, such as catarrh and erysipelas, prevail simultaneously 
in both classes. 

J. The state of health, of convalescence or of disease, has like- 
wise an influence upon the facility of development of various 
affections. 

It would be absurd to rank health among the preparatory causes 
of disease. There are, however, certain affections which are 
observed only in those who previously enjoyed perfect health; 
such is the ephemeral fever produced by an evident external cause ; 

* This affection, peculiar to the skin, has received the name, grenouilles. See 
the Memoir of Parent-Duchatelet upon porters employed to unload boats. — An- 
nales de hyg. publ. t. iii. p. 245. 

fOf 670 boat porters examined by Parent-Duchatelet, one only had an ulcer. 

\Annnl. d'hyg. et de mid leg. t. iii. p. 294. 

|| Annal. d'hyg. et de mid. Ug. t. iii. p. 5. 



44 ETIOLOGY. 

the same cause would have excited in another person a more 
serious malady, etc. Descriptions of epidemics also exist, in which 
the prevailing disease attacked healthy individuals by preference, 
as it were, while feeble and infirm persons escaped. But the 
opposite of this has been almost constantly observed, and a dis- 
eased condition must always be considered as favorable to the 
development of prevailing complaints, and as a predisposing cause 
of various affections. Diemerbroeck states, that in the plague of 
Nimegue, all those who were attacked by any complaint whatever, 
were soon afterwards affected with the contagious malady ; the 
same was remarked in the epidemic cholera of Paris in 1832, and 
has been noticed in many other epidemics. Oedema of the glottis 
scarcely ever occurs except among patients already seriously ill. 
Convalescence is accompanied by a debility and susceptibility, 
which greatly accelerate the action of morbific causes. 

K. Pregnancy, likewise, renders the system liable to different 
diseases. Many women experience some nervous affection during 
gestation, as vomiting, depraved appetite, cramp and convulsive 
movements; or plethoric accidents, as headache, ringing of the 
ears, oppression, or palpitations, which yield to venesection, etc. ; 
during the period immediately succeeding delivery, the suscepti- 
bility of women to attacks of acute disease, to which the epithet 
puerperal is given, is singularly augmented ; every one knows 
how frequent these affections are ; the uterus with its appendages 
is most usually the origin of disease ; acute metritis supervenes 
more often under these circumstances, than in any others. The 
same is true in inflammation of the mammas during lactation. 
Nursing women, and those who have lately weaned their children, 
are very easily affected by the action of the productive causes of 
rheumatism : they often experience its attacks, and it then receives 
the popular name of milk pains. 



2. Individual predisposing Causes, properly so called. 

Having pointed out the various conditions which we have 
styled aptitudes, and which may predispose to disease, we shall 
briefly examine the individual predisposing causes, properly so 
called, which belong to the second series. 

A. General causes prevail in the class of the circumfusa ; still 
there . are some that act upon isolated individuals, as the fre- 
quenting of dissection rooms and hospitals, which disposes to dis- 
ease of an adynamic character ; also an habitual residence in con- 
fined, ill-aired, and overheated apartments, which renders the 
body more sensible to external cold, and more likely to be affected 
by it. 

Change of climate, which is a general predisposing cause for 
troops transported to the colonies, is more frequently an individual 



ETIOLOGY. 45 

predisposing cause. The inhabitants of the country when they 
come to reside in cities, almost always experience some disorder ; 
within the first few days, diarrhoea, or severe fever after some 
months' residence. The greater number of those who retire to the 
country, after having spent the first part of their lives in cities, 
as for instance, merchants who have become independent, or pub- 
lic functionaries who have lost their situations through political 
vicissitudes, soon experience more or less disturbance of health, 
which often results in death. But we should observe, that, in all 
such cases, many other alterations assist the mere change of dwell- 
ing-place in causing the result thus observed. 

B. Some individual predisposing causes are found among the 
applicata. Clothing, when too thin, favors the action of causes 
productive of catarrh and rheumatism. That which is too 
warm, determines indirectly a similar effect by increasing the 
susceptibility. The form of the dress, which changes according 
to the fashion and tastes of the various classes of society, is not 
without its influence upon the health. Many physicians think 
that the costume adopted since the French Revolution, has con- 
tributed very much to render pulmonary consumption more com- 
mon among females, and croup among children ; the exposure of 
the neck, the arms, and the upper part of the chest, accounts 
apparently for the frequency of these diseases. It has been said 
also, that the Greeks and Romans, whose legs were habitually 
bare, were more subject than we are, to erysipelas of those parts. 

Among the morbific agents belonging to the applicata, those 
acting through the medium of compression probably produce the 
most remarkable effects. 

The immediate effect of all compression is to diminish the vol- 
ume of the parts subjected to it, and almost constantly to inter- 
fere with the action of the organs, to retard the circulation of 
the fluids, and particularly of the venous, and even the arterial 
blood. In this case, compression may have a rapid and manifest 
effect, like the specific causes ; the gangrene which occurs in a 
tumor, whose base is surrounded by a ligature, and asphyxia 
caused by compression upon the trachea, are examples ; but in the 
great proportion of cases, the effects of compression manifest 
themselves slowly, like those resulting from the action of predis- 
posing causes. 

These effects, which are exceedingly various, might belong to 
either predisposing or determining causes ; still we have included 
them under one head, so as not to separate them from those phe- 
nomena which are more interesting when studied collectively; 
they depend on the nature of the compressing agents, the struc- 
ture of the parts compressed, the time during which the compres- 
sion is continued, the extent of surface compressed, and the 
force with which it is applied. 

1. The agents capable of producing compression are very nu- 
merous : some are applied to the surface of the body, as the cloth- 



46 



ETIOLOGY. 



ing, particularly corsets, garters, and girdles ; others, whose 
action is internal, are either foreign bodies or morbid growths, as 
tumors, effused liquids or gases, which become an actual cause of 
various secondary disorders by means of the compression they 
maintain upon the neighboring organs. 

The elastic corsets used by most females, are, probably, one of the 
causes which lead to the development of organic disease of the 
lungs and heart, particularly during the period of growth and 
that of pregnancy, when the chest should rather be increased in 
volume. In this latter case, there are many other inconveniences : 
the pressure upon the abdomen prevents the development of the 
uterus, tends to give it an abnormal position, and may excite 
abortion. Their action upon the mammas is not less marked : it 
prevents their attaining tiie increased volume which they should 
acquire, flattens the nipple, and renders nursing difficult or im- 
possible. The stomach and intestines thus compressed, some- 
times assume a faulty position, the exercise of their functions 
is always impaired; the inconvenient and noisy borborygmi, so 
frequent in females, are probably owing to the compression of the 
intestines by corsets ; this is scarcely ever observed in men. 

Compression, however slight, if long continued, caused by sur- 
gical apparatus, or by a simple bandage intended to support the 
dressing of an issue, may sensibly diminish the volume of the 
part compressed, and sometimes may occasion oedema of that por- 
tion of the limb in which the venous circulation is obstructed. 
Garters, when very tightly drawn, may cause varicose dilatation 
of the veins. Very narrow socks worn in childhood, change the 
conformation of the toes, and at any age produce a thickening of 
the skin and the development of those hard and painful tumors 
called corns ; but friction contributes to this result. The synovial 
cyst called hygroma, which is formed in the neighborhood of the*!,, 
knee and elbow, in workmen whose employment forces them to ' 
press continually upon these parts, either with the instrument they 
use or against the table at which they work, is an analogous for- 
mation. Compression of the neck, by a tight cravat, excites 
or increases the distension of the cerebral vessels, and favors 
haemorrhage and inflammations of the brain. 

Internal compression, caused by a tumor, affects the organs in 
various ways. It attracts but little notice when the tumor is be- 
neath the skin or between the muscles, because the resistance is 
slight and the compression consequently less. The case is nearly 
the same when the tumor occupies the superficial portion of the 
abdomen, whose anterior parietes are susceptible of considerable 
extension. But it is otherwise within the skull, the thorax, the 
nasal fossae, and even the inferior parietes of the mouth. 

The primary effect of tumors (Weloped within the skull is to 
compress the corresponding cerebral hemisphere, and to induce 
more or less complete paralysis of the muscles of the opposite 
side. If the tumor be near the bony arch of the skull it often hap- 
pens that it gradually reduces the thickness of the bone, even to 



ETIOLOGY. 47 

the tenuity of parchment, and in some cases completely perforates 
it, making its appearance through the aperture ; fungous tumors 
of the dura mater often present this series of phenomena. Analo- 
gous effects occur in the chest : such as functional disturbance, 
and absorption of the parietes. If the tumor be in the vicinity of 
one of the axillary regions, it sometimes causes, by compression 
of the artery, a progressive decrease in the force of the pulse 
upon that side, and by compression of the veins and lymphatics, 
oedema of the corresponding limb. 

If the compressing agent be a fluid, its effect is only distension 
of the natural or adventitious cavity which encloses it, and inter- 
ference with the action of neighboring organs, as is uniformly 
noticed in the abdomen, often in the thorax, and occasionally in the 
skull, where ossification is incomplete ; but absorption of the 
bony walls never occurs, as it does from solid tumors. 

2. The structure of compressed parts has great influence upon 
the phenomena of compression. This may be easily appreciated 
in the chest, where the organs differ very much from each other 
in texture, and whose parietes are composed of both hard and 
soft parts. It is observed that the softer and more flexible the 
tissues, the less change occurs in their texture, in consequence 
of the tumors which compress them ; on-the other hand, the harder 
they are, the greater effect is produced. Thus an aneurismal tu- 
mor of the arch of the aorta causes absorption of the sternum, 
cartilages of the ribs in front, and of the vertebras behind, while, 
for a long time, it simply displaces the heart, and diminishes the 
volume of the lungs. 

If the trachea be compressed, the cartilaginous rings are first de- 
stroyed ; their uniting membrane resists for a long time, as do the 
intercostal muscles when the ribs and their cartilages are already 
^•absorbed. In the case where the tumor opens into the bronchial 
v tubes, the oesophagus, pleurae or pericardium, and causes death, 
the comparative examination of the different parts shows that 
the lesion of those which are hard and resistant is greater and of 
earlier date than that of the soft parts. We should notice that there 
is here something special in the nature of the compression, on ac- 
count of the pulsation occurring in aneurismal tumors ; both per- 
cussion and compression exist. The application of this principle 
and the proof of its truth is found in the tumor known as ramila, 
which causes absorption and deformity of the lower maxillary 
bone and of the teeth therein inserted, and only occasions simple 
displacement of the soft parts. But in all these cases the latter 
resist only by reason of their elasticity under the force of the 
compressing agent. If compression be so applied as that they 
cannot thus escape it, they feel its effects, and indeed much 
sooner than the firmer tissues ; as is observed by the formation of 
eschars on those portions of integument compressed between super- 
ficial and projecting bones, as the sacrum, the great trochanters, 
and the bed on which the patient lies. 

3. The effect of compression is proportionate in great measure to 



48 ETIOLOGY. 

the time during which it is exercised. When short, even though 
very violent, provided it be not carried far enough to cause altera- 
tion in the tissue of the organs, the latter immediately regain their 
size and the full exercise of their functions. After longer com- 
pression, for some days, or weeks, for instance, the natural condi- 
tion is slowly, but may be completely regained. It is far otherwise 
when compression has been continued for a considerable time, as 
for years ; it then most usually happens that the suffering organ 
does not regain its primitive volume ; this is particularly the case 
with the lungs after pleuritic effusions. There is, moreover, this 
difference between compression of short and long duration, that in 
the former, the diminution in volume seems alone owing to the 
liquid contents being discharged and the solid parts brought more 
closely together, while in the latter there is a real decrease in the 
solids themselves, partial emaciation or atrophy. 

4. The extent of surface over which compression is applied, also 
modifies its effects. A very narrow bandage may penetrate the 
tissues; a broader one would not. When compression is main- 
tained upon one particular portion of a limb, the circulation be- 
comes arrested below the point of application. This does not 
happen if the compression extend to the extremity of the limb. 
Such are the chief effects of compression in the development of 
disease either primitive or secondary, whatever be the agent or the 
recipient organ. 

Beds also deserve some attention. The habit of sleeping upon 
feathers, by increasing cutaneous transpiration, favors the forma- 
tion of urinary calculi and disposes to nephritis. A hard bed does 
not seem a predisposing cause of any complaint. Seats, which 
are very soft, and particularly those furnished with feather cush- 
ions (bergeres), are conducive of sanguineous congestion in the 
uterine and hemorrhoidal vessels. 

The daily use of cold baths is thought to predispose to inflamma- 
tory disease by their tonic action upon most of the organs. Warm 
baths, often repeated, produce an opposite effect ; they weaken the 
constitution, and predispose to chronic discharges and diseases of 
debility. Want of cleanliness generally favors the development 
of all contagious and cutaneous diseases. Excess of cleanliness, 
combined with the use of perfumes and the various resorts of lux- 
ury, seems to aid in the production of nervous diseases. 

C. Ingesta. Food, liquids and remedies may dispose to various 
diseases when improper use is made of them. 

In health, the quantity oifood and liquid should vary according 
to age, strength, occupation, habits, etc. Their moderate and 
temporary increase or diminution does not usually produce func- 
tional disturbance, but beyond certain limits the health becomes 
deranged. 

A decided and long continued diminution in the ordinary quan- 
tity of food causes analogous loss of strength and flesh ; its increase 
produces plethora. Habitual excess in food seems to dispose to 



ETIOLOGY. 49 

organic disease of the stomach and intestines, which is not 
always avoided by extreme abstinence. The daily abuse of fer- 
mented liquors, of wine or alcoholic drinks, gives to acute diseases 
so grave a character as to render them generally fatal. 

Wine and alcoholic liquors are more pernicious in their effects 
when drunk between meals than when taken into the stomach 
mixed with solid food. The disease known as delirium tremens 
is often owing to the abuse of these drinks, or to their sudden ab- 
straction from the intemperate.* According to some physicians, 
sudden death and spontaneous combustion are not rare in persons 
who use habitually a large quantity of alcohol. The immoderate 
use of coffee disposes to cerebral congestion and inflammation of 
the stomach ; tea, on the contrary, weakens this viscus gradually, 
and seems to predispose to chronic discharges. Some authors 
have attributed the frequent occurrence of leucorrhea in women re- 
siding in cities to this cause, and others have seen the use of 
beer produce blennorrhagia in both sexes. It has been said that 
the use of cider and beer in England and Normandy, is the chief 
cause of the rheumatism so common in those countries ; but is not 
this rather to be attributed to the conditions which prevent the cul- 
tivation of the vine, and to the moisture of the soil 1 

The bad quality of food containing in itself but little nutriment, 
or altered by putrefaction, fermentation or mouldiness, disposes 
to disease of more or less severity, as inflammations of the diges- 
tive canal, adynamic fevers, scurvy, etc. The use of bad water, like 
that drunk on shipboard during long voyages, of sour wine, or 
badly prepared cider, produces analogous effects. 

Variety in food is necessary to man. The satiety experienced 
after having for a long time used the same alimentary substances 
and the satisfaction experienced by a change, prove the truth of this 
assertion. The exclusive use of any one article of food, in those 
whose unrestrained habits would have been opposed to such a 
course, almost always terminates in disease ; farinaceous food dis- 
poses to plethora, fat and oily articles induce chronic discharges, 
and animal substances give rise to inflammatory complaints of 
every description ; salted food, in conjunction with want of vegeta- 
bles and the fruits of the season, produces scurvy; the prolonged 
use of a scanty regimen is a frequent cause of obstinate constipa- 
tion and various digestive troubles, in those who fast throughout 
Lent. 

Spices and powerful condiments, as pepper, mustard, pimento, etc.. 
increase, at first, the energy of the stomach ; but this viscus becomes 
accustomed to the action of such excitants, which soon cease to 
stimulate it, and inactivity frequently succeeds the temporary ex- 
citement. The abuse of these substances may cause inflammation 
of a part or the whole of the digestive canal, of the mouth, the 
pharynx, stomach and intestines. 

Medicines, considered by most persons as means of preserving 

* Bl^ke, Edinb. Med. and Surg. Jour., t. xix. 
5 



50 



ETIOLOGY. 



and re-establishing the health, may sometimes disturb it. Reme- 
dies styled precautionary, far from strengthening, often injure the 
health. Repeated emetics have finally caused weakness or even 
inflammation of the stomach, and purgatives thus used have had 
the same effect on the bowels. The use of medicine not indicated 
in the course of a disease, may instantly cause a new affection or 
aggravate the existing complaint. 

D. Excreta. The evacuations may vary considerably without 
derangement of the health ; usually, one being augmented, another 
is diminished, so that the balance of the system is preserved. 
Slight changes in the quantity of the evacuated matters, either 
more or less, do not suffice for the production of disease ; but when 
the disproportion between the excreted matter and the reparatory 
means becomes very considerable, it acts upon the constitution and 
so modifies it, as to predispose it to various affections. If the quan- 
tity of food daily assimilated be greater than the portion excreted, 
a tendency to plethora and inflammations of every kind is the con- 
sequence ; if, on the contrary, absorption is not sufficient for the 
reparation of the daily losses of the economy, the body gradually 
diminishes and is liable to complaints resulting from debility. 
Profuse sweating, copious salivation, too great secretion of milk in 
nurses, etc., cause the latter effect. In man, venereal excess and 
masturbation act in a similar manner, with this peculiarity, that 
nervous phenomena almost always aceompany the debility arising 
from repeated evacuations of semen. 

The debility induced by excessive evacuations, brings into ac- 
tion the occasional and determining causes of disease. Thus a 
man who, during his whole life, has exposed himself with impu- 
nity to the inclemencies of weather, is attacked with rheumatism, 
when exposed after excess in venereal indulgence.* The same 
circumstance disposes to attacks of yellow fever at St. Domingo ;f 
and Diemerbroeck J observed at Nimegue, that all who married 
during the continuance of the plague, were attacked by the con- 
tagion a few days after their nuptials. Abundant haemorrhage, 
bleeding, and repeated purgatives, have had the same effect during 
many other epidemics. 

Natural or artificial evacuations, when reproduced at nearly 
equal intervals, have a very different effect, especially when they 
are confined within certain limits ; the system repairs and sup- 
ports these losses, either by the diminution of other evacuations, 
or by the assimilation of a greater proportion of food ; from this^ 
plethora results. Periodical evacuations, natural or artificial, cause 
this to yield, but at the same time they increase the tendency to 
its reproduction, so that nothing more strongly predisposes to ple- 
thora, or at any rate, to strengthen the predisposition to it when 

* Essai xur la Rhvmatisme, 1813. 

| Traite.de la Fieore javne, par Bally. 
j Diemerbroeck, de la Pesle de Nintegue. 



ETIOLOGY. 51 

existing, than these evacuations. The menstrual discharge in 
females, periodical haemorrhoids in males, and habitual bleeding 
in both sexes, often produce this effect. 

The suppression of habitual evacuations, the omission of cus- 
tomary bleeding and purging, may tend to produce various com- 
plaints ; but they act generally as occasional, rather than predis- 
posing causes. 

E. Gesta. The precise degree of action and rest, of sleep and 
waking, to which man should restrict himself in order to preserve 
his health, cannot be determined ; nevertheless there are certain 
bounds which he can rarely pass without deranging the harmony 
of the functions. 

Any marked disproportion between exercise and repose always 
injures the health ; too great fatigue induces a kind of debility, and 
gives an adynamic character to acute affections developed under 
such conditions. It has been said of country people, that usually 
they have but one disease in their lives, and. that fatal to them . 
Partial exercise may also predispose to certain affections ; the con- 
tinual and repeated movements of the arms, for instance, seem 
calculated, in a greater degree than those of the lower limbs, to 
bring on haemoptysis in those subject to it, and to hasten the 
progress of cardiac aneurism. 

The want of exercise is far more replete with danger than the 
opposite extreme ; this is more decidedly the case in proportion as 
the individual has need of exercise, on account of his age, habits, 
and strength. Thus it is most injurious to children, to robust per- 
sons, and to those who have always led an active life. It is ob- 
served that a sedentary life is less prejudicial to the female than 
to the male, either because, from youth, habit has lessened in her 
case the troubles arising from it, or because such a life is more 
conformable to her peculiar destination, and consequently to her 
constitution. Want of exercise is the source of many disorders. 
One of its first effects, is loss of appetite and slow digestion ; dys- 
pepsia frequently recognizes this as its sole cause, and yields only 
to regular exercise. Prolonged inaction causes debility of the lo- 
comotive organs, favors sanguineous congestion towards certain 
parts, and vitiates nutrition ; the body increases in size and loses 
strength ; adipose polysarcia, mucous discharges, scrofula, and 
oedema, are the different results of this inaction when carried to a 
great extent, the effects varying according to the constitution of the 
individual. The same cause, in a less degree, exercise not being 
quite sufficient, disposes to plethora, especially in high livers. In- 
action of a single limb usually produces mere local effects, such as 
weakness, diminution of size, and atrophy of the part which is kept 
motionless. 

That change, which is necessary in all the acts of life, is espe- 
cially so in regard to the positions of the body. The restraint 
arising from too long retention of one position, the need of chang- 
ing it at intervals, even during sleep, had already established the 



52 



ETIOLOGY. 



truth of the above assertion, even prior to its adoption as a hygi- 
enic precept. The upright posture, when habitual, disposes to 
varicose affections, oedema, of the legs in both sexes, varicocele in 
man and prolapsus uteri in women ; the sitting posture, to haemor- 
rhoids and engorgement of the abdominal viscera; the kneeling pos- 
ture induces lumbago and early curvature of the spine ; horizontal 
posture favors cerebral congestion, epistaxis and apoplexy. This 
latter position, when maintained for many months, on account of 
fractures of the lower limbs, has often seemed to be the main 
cause of calculous formations in patients who had never previ- 
ously been so affected. 

A proper division of our sleeping and waking hours is useful 
in maintaining health. From six to eight hours' sleep are neces- 
sary for adults ; less is requisite for old persons, and more for chil- 
dren. But here, as elsewhere, general rules admit of exceptions; 
some persons need nine or ten hours' sleep; four or five are suf- 
ficient for others. Prolonged sleep induces general sluggishness, 
and predisposes to plethora and cerebral affections. Those who 
retire and rise very late, who sleep in the daytime and remain 
awake at night, hardly ever attain to an advanced age. After 
long watchings, nervous affections are frequently developed, and 
particularly great irritability of the nervous system. 

F. Percepta. The sensations, passions, and intellectual efforts, 
when they exceed certain limits, become predisposing causes of 
disease. 

Sensations, habitually very feeble, augment by degrees the sen- 
sibility of the organs which are their seat, to such extent that they 
become unfit to bear those which are moderately powerful : this 
is observed in individuals who remain for a long time in a dark 
abode, and among those who live upon very unstimulating food. 
Sensations habitually very lively, on the contrary, exhaust the 
sensibility of the organs, and render them unfit to fulfil their func- 
tions. 

The passions have a very remarkable influence upon the de- 
velopment of disease. While the mild and varied, favor the har- 
mony of the functions, the strong and exclusive, are injurious in 
the same degree. They not only may affect the system in a sud- 
den and marked manner, as in the instances of derangement, 
instant death and hectic fever from moral causes, as we have seen 
in the enumeration of determining causes ; but they also, and far 
more frequently, give rise to an exaggerated sensibility which 
peculiarly predisposes to nervous affections. Prolonged grief seems 
to have a powerful influence in developing organic diseases es- 
pecially cancer. 

Mental labor, when excessive, predisposes to nervous affections • 
but it does not hence follow, as has been supposed, that study is 
contrary to nature. It is a law of nature, that the greatest pos- 
sible intellectual and physical development should be simultane- 
ously attained. The exercise of the mind, meditation and study 



ETIOLOGY 53 

are necessary to the development of the intellect, as motion is to 
that of the body. When the object of study suits the taste of the 
student, when it alternates with some manual occupation or with 
suitable exercise, it rather benefits than injures the health. Many 
literary men, physicians and mathematicians, have attained to 
very advanced age; and if there have been those who have died 
from excessive application, the number is very small. When, 
however, studies are continued daily for many hours, and relate 
to subjects in themselves uninteresting and irksome to the one 
employed in them, when they are not varied and interrupted from 
time to time by exercise, the body is injured in its development ; 
the energy of the mental powers may be blunted, and in early 
youth the germ of the most brilliant faculties blighted. 

Antecedent diseases may be added to these different individual 
predisposing causes ; they strongly favor the action of those spe- 
cific or occasional causes which are likely to excite anew the 
above named diseases. A first attack of hysteria or rheumatism 
not only indicates the aptitude of the patient to be thus affected, 
but seems to increase the tendency to repeated attacks. It has 
often been noticed in ulterior attacks of hysteria and rheumatism, 
that very slight occasional causes sufficed for the development of 
these affections, while the first attack required the influence of 
very powerful agency. 



ARTICLE THIRD. 

Occasional or exciting Causes. 

Occasional causes, as we have stated, are those which excite 
disease without determining its nature or situation, and which act 
only with the concurrence of the predisposition. 

These have not the importance which attaches to those of the 
first two orders ; but because they do not belong to the particular 
history of any one disease, they are, more than the others, within 
the domain of general pathology : their enumeration is therefore 
necessary. 

The impression made by very cold or very hot air, by the 
north or south wind ; the action of a current of air upon the 
whole body, or of a smaller draught {vent coulis) upon one part in 
particular ; the sudden passing from a very warm to a very cold 
apartment, and vice versa, ; a short stay in a damp house, newly 
built ; a temporary change in the thickness or form of the gar- 
ments ; immersion in a very hot or very cold bath, exposure to 
rain ; wet clothes retained upon the body ; errors in diet, as the 
excessive ingestion of food, otherwise of good quality ; the use 
of inferior or badly prepared food, difficult of digestion, taken 
at an unaccustomed hour or hastily eaten ; very hot or very cold 
drinks, or those injurious by their quality; the suppression of 
5* 



54 ETIOLOGY. 

certain natural evacuations, as the perspiration, lochia, milk, 
and menstrual discharge ; or of a morbid or artificial discharge, 
as that of leucorrhea, chronic ulcers, long established setons or 
blisters; an habitual hasmorrhagic discharge which has become 
necessary ; a natural evacuation considerably increased ; untimely 
venesection ; emetics and purgatives administered without indica- 
tion ; excessive fatigue ; an unusual amount of rest ; cries ; singing ; 
shouts of laughter; running against the wind; prolonged watch- 
ing ; physical or moral shocks ; lively emotion, as joy or terror ; 
necessary mental strife ; retrocession of gout ; disappearance of 
exanthematous affections ; sudden cessation of some other com- 
plaint; such are the chief occasional causes of disease. 

These differ from special and predisposing causes by not being 
connected with the history of any affection in particular. One 
occasional cause may excite any disease, and the same disease 
may be induced by every kind of occasional cause. If there 
were any doubt as to the correctness of this proposition, the ex- 
amination of any treatise on pathology would suffice for its re- 
moval ; in the portion devoted to the etiology of each disease, the 
acute in particular, all the occasional causes we have just named 
would be almost literally enumerated. It is quite otherwise with 
the determining causes ; they differ either in themselves or as re- 
gards the parts upon which their action is exerted in each kind of 
disease. Notwithstanding this great difference between them, 
there are many points of contact, where the occasional, are, as it 
were, mingled with the determining and predisposing causes. For 
instance, is cold a determining or an occasional cause of rheuma- 
tism ? The different opinions of physicians prove that this is a 
point not easily decided. On the other hand, if we compare 
occasional and predisposing causes, it will be seen that the same 
circumstances may belong to each. There is, it is true, this differ- 
ence, that in the one case, the cause is momentary in its action, 
while in the other, that action has been of long duration; an error 
in diet is an occasional cause ; habitual intemperance, on the 
contrary, is predisposing; the distinction is very marked when 
our examples are extreme cases, but becomes more obscure in 
proportion as they are less so ; excesses which are prolonged for 
many days, for one or several weeks, can hardly be said to belong 
decidedly to either class. There are some circumstances where a 
simple error in diet, usually considered one of the occasional 
causes of disease, becomes a predisposing cause. During epidemic 
variola or prevailing plague, excessive drinking or venereal indul- 
gence often repeated in the space of a few hours, have frequently 
been observed to favor the action of the pestilential or variolic 
virus, and the individual who for months had braved contagion 
with impunity, has been attacked immediately after being debili- 
tated by these causes, which, in these cases, evidently acted as 
predisposants. 

This division of morbific causes presents some defects ; nature 
does not submit herself to our divisions in this instance any more 



ETIOLOGY. 55 

than in others ; she cannot be rigorously bound by any. The 
proposed arrangement seems more methodical and practical than 
others ; above all, it is particularly suitable as our guide in the 
study of morbific causes, considered in regard to their mode of 
action. 



ARTICLE FOURTH. 
Mode of Action of Morbific Causes. 

All the organs of the human body are not equally exposed to 
the action of morbific causes ; the alimentary canal, the lungs and 
the skin are more apt to receive from them an injurious impres- 
sion on acccount of their more intimate relations with external 
objects. Huf eland in his Pathogeny* has for this reason denomi- 
nated them atria morborum, the gates of disease. To them should 
be added the brain and nerves, which especially in civilized man, 
are directly exposed to the action of a large class of morbific 
causes. 

Among the agents which disturb the health, there are those 
which, impelled by a greater or less force communicated to them, 
or by means of their chemical qualities, penetrate into the substance 
of the organs ; their action is purely physical or chemical ; their 
effects would be the same upon the dead body. Among these are 
bodies which cause wounds, caustic substances and fire. Others 
influence only the living tissues, and can act only by the power of 
vital laws. Such are acrid plants and rubefacients, whose action 
is confined to the skin and mucous membranes with which they 
are in immediate contact ; food and drink, and perhaps poisons, 
and certain miasmata which penetrate the system through the ab- 
sorbent vessels, and whose morbific effects may be felt very far 
from the spot where they were first deposited ; the passions, sensa- 
tions and intellectual efforts which manifest themselves through 
the nervous system, are also of the same class. 

We shall not extend farther our remarks upon the mode of ad- 
mission of these causes into the system ; but will proceed to point 
out the modus operandi of the three classes of causes which we 
have proposed. 

§ I. The action of specific causes is usually evident, although 
not always easy, and often impossible to explain. 

When a wounding instrument penetrates any part, fractures a 
bone, injures a tendon or an artery, we suppose the force which 
divided these organs to have been superior to that which preserved 
their continuity; we can likewise account for the disordered mo- 
tions, and the flow of blood which result from such injuries. A 
foreign body in the trachea or bladder causes symptoms easy of 

* Iludog, disease ; ylrouat, to exist. 



56 ETIOLOGY. 

explanation, because its action is wholly mechanical. The case is 
similar when the passage of alimentary matter is intercepted, 
where the intestines are compressed by a tumor, or strangulated 
by a peritoneal, or hernial stricture. We can understand likewise 
how a violent contraction of the muscles may cause hernia, dislo- 
cation, fracture of the patella, or rupture of a tendon ; but most of 
the causes we have enumerated, while they exert a mechanical 
action upon living organs, produce other effects subordinate to the 
vital laws. Thus, divided or displaced parts become red, hot, 
painful and swollen ; a new secretion is established in them, etc. 
There is nothing surprising to us in these phenomena, because we 
are accustomed to observe them. But if we desire to examine 
them thoroughly and to know the mechanism of their production, 
we are compelled to acknowledge our ignorance, unless we are 
willing to substitute error in its place, or veil it by language which 
imposes even upon ourselves. Notwithstanding the progress of 
modern chemistry, we are constrained to say the same thing in re- 
gard to the action of the gases which produce asphyxia. We 
know that some suspend gradually, and others immediately the 
phenomena of life; we are acquainted also with the changes" 
caused by some of these agents in the color and consistence of the 
blood ; but asphyxia still remains unexplained. The action of the 
poisons upon the economy is equally well demonstrated, but quite 
as inexplicable. Why is a species of coma caused by the narcotic 
poisons ; inflammation of the stomach and intestines by the acrid, 
and gangrene of various parts by the septic? These are questions 
which do not admit of reply. We can more easily understand the 
effects of fire and caustics, because they are partially the same 
upon all organized bodies; but their peculiar action is quite as 
much beyond our penetration. 

The action of contagious principles is yet more obscure. To a 
certain extent we are acquainted with the agents of which we have 
just spoken ; we appreciate the physical and chemical properties 
of the irrespirable and the deleterious gases, caustics and some poi- 
sons. This is not the case with contagious principles, for they 
escape our senses, and those whose action is most easily appreciated, 
as vaccine and variolic virus, cannot be separated from the vehicle 
which contains them, and studied in regard to their properties. 
Thus it is only by a process of reasoning that we admit their ex- 
istence. 

Many authors have compared the development of contagious 
diseases to that of vegetables, and likened the contagious principles 
to their seeds. If we bear in mind what has previously been said 
of contagion, it will be easy to see the principal points of analogy 
between them; but the resemblance is far from complete. The 
existence of plants and the seeds from which they spring, is mani- 
fest and does not admit of doubt. The existence of contagious 
principles, on the contrary, is only admitted as a consequence of a 
series of facts which are thus clearly explained, and which other- 
wise would remain inexplicable. Certain diseases being capable 



ETIOLOGY. 57 

of transmission from affected to healthy individuals, this mode of 
transmission has been called contagion, and the inappreciable 
agent is called a contagious principle. 

The action of contagious principles is obscure for many other 
reasons. Do they act directly upon the nerves of the part with 
which they are brought in contact, or are they absorbed into the 
rest of the system 1 These two opinions have been supported by 
quite plausible arguments ; and each might be true as regards cer- 
tain poisons, for it is possible that all may not obey the same laws 
in their manner of entering the system. 

The efficacy of cauterization practised fifteen or twenty days 
after the bite of a rabid animal, has led some practitioners to the 
conclusion that the poison of rabies is not absorbed, and that being 
simply deposited in the soft parts which received the wound, its 
action is at first confined to the nervous extremities which there 
exist, from whence, in time, it extends to the rest of the nervous 
system. But in other contagious diseases, the pain, swelling, 
and redness which occur in the track of the lymphatic vessels and 
glands, seem to prove the absorption of certain poisons, although 
some authors have attributed these phenomena to sympathy. 
Admitting absorption, what is the absorbing surface, if these poi- 
sons are volatile ') Is it the skin, or the mucous membrane of the air 
passages, into which they are carried with the air 1 or that of the 
alimentary canal where they enter mingled with the food or sali- 
va? Some authors have supposed that contagious principles 
cannot act upon the membrane of the stomach, because all the 
substances introduced into this viscusare there digested and conse- 
quently become changed. This is an ingenious supposition ; but 
if we remember that variola has been inoculated by mingling some 
of the dried scabs with the food and drink, it will be allowed that 
this supposed decomposition of the virus by the action of the 
stomach or by the gastric juice is still very doubtful. Others have 
asserted that contagious principles could be absorbed by those or- 
gans only in which their symptoms appeared ; that variola and 
scarlatina were contracted by the skin, syphilis by the mucous 
membranes, etc. ; but in the existing state of our knowledge, it is 
more reasonable to admit that nearly all the contagious agents may 
be absorbed by every surface with which they come in contact ; 
and that being once introduced into the economy they act specially 
upon those organs which seem most congenial to each of them. 

After having studied the action of the evident causes of disease, 
Ave shall examine in like manner the predisposing causes, com- 
mencing with aptitudes. 

$ II. Aptitudes. 

The age, sex, temperament, constitution, the degree of comfort, 
the healthy or diseased condition, and pregnancy, seem neither 
actively to concur in, nor to oppose, the production of disease. 
Their influence is appreciated with difficulty, but their action 



58 ETIOLOGY. 

cannot be doubted when general conclusions are drawn from a 
large number of facts. If, for instance, we collect all the obser- 
vations which relate to any particular affection, and observe that, 
in every case, or at least in the greatest number, the disease 
declares itself at a certain age, and in persons of certain tempera- 
ment, we must admit that these circumstances constitute favorable, 
perhaps necessary conditions for the development of such disease. 
Thus, croup is incontestably more frequent during infancy than at 
other periods of life, phthisis in youth, arterial aneurism and 
cancer in adult years, haemorrhage and softening of the brain in 
old age. Females are more disposed to hysterical affections; 
males, to hypochondriasis ; some epimedics prevail among the 
poor, others among the opulent, etc. In fact, the influence of 
aptitudes grows more obscure, as we descend from general conclu- 
sions to individual applications ; for instance, it does not absolutely 
follow because scrofula affects children more frequently than 
adults, and shows a preference for the lymphatic temperament, 
that these two conditions have always concurred in its production, 
when observed in such circumstances ; but this does not invalidate 
the fact that, generally, this age and temperament favor the affec- 
tion. It is no reason because typhoid fever occurs chiefly in 
youth, rarely in the adult, and never after the age of fifty-five, 
that the season of youth has an active agency in its production, 
but it shows that the liability to contract it, is bounded by certain 
limits in regard to age, beyond which it does not pass. 

The influence of age in the development of disease, is far more 
evident, than that of either temperament, constitution, sex, or 
degree of comfort. There is no disease incompatible with any 
temperament or constitution, or with either sex ; while certain ages 
are exempt from some affections, and others are peculiarly exposed 
to them. 

It is universally conceded, that of all the conditions comprised 
under the name of aptitudes, hereditary transmission has the 
greatest influence in producing disease. In some affections, in- 
deed, it is an active predisposing cause, rather than a mere 
aptitude. Children of phthisical origin are in imminent peril of 
this fearful disease, by reason of that origin alone; and the larger 
proportion of them are attacked by it, however they may be cir- 
cumstanced. The influence of birth is less powerful in some other 
diseases, as rheumatism, stone, apoplexy. Children of parents 
thus afflicted are, other things being equal, more liable to be 
affected; but other causes must often concur in order to their 
production, and even then they are not all attacked. 

§ III. Predisposing Causes, properly so called. 

Although usually obscure, the action of predisposing causes can 
often be explained in a satisfactory manner. It is easy to conceive 
how certain diseases, as indigestion and abortion, may be caused 
by too tight clothing or corsets. The disposition to plethora, 



ETIOLOGY. 59 

when it follows the use of very nutritious food, and anaemia, which 
is the effect of abstinence and poor diet, may be easily accounted 
for. The debilitating influence of excessive evacuations of every 
sort, and the tendency to inflammation which results from the 
suppression of habitual evacuations, is quite as clearly explained. 
So it is with regard to the effect of habitual repose or excessive 
fatigue upon the health. Nervous disease in anxious or melan- 
choly persons, or in those who devote themselves exclusively to 
mental labor, is naturally connected with the causes productive of 
these affections. The influence of the air and the dwelling is 
commonly more obscure, although plausible explanations have 
been given in regard to it. 

Predisposing causes must not be confounded with predisposi- 
tions ; the latter depend, but not constantly, upon the former. All 
persons are not uniformly affected by the same predisposing causes, 
and a predisposition to disease cannot be accurately determined 
by the apparent power of the causes which produced it. In one 
case, a slight predisposing cause will establish a very decided 
predisposition; in another, a number of such causes, of greater 
power and longer continued action, will have far less effect, or 
perhaps none whatever. In many instances we are compelled to 
acknowledge a decided predisposition to certain diseases in those 
who have not been exposed to any of their developing causes. 

Whenever a disease appears without apparent cause, a frequent 
occurrence in internal pathology, we must have recourse to a 
latent predisposition to explain its production ; and this doubtless 
consists in a peculiar modification (whose essence is wholly un- 
known) either of the whole system, or of one or many of its 
constituent parts. Thus in pneumonia, erysipelas, or articular 
rheumatism, it is in almost every case impossible to point out, 
from a consideration of the antecedent circumstances, the causes 
which have produced either of these affections. Great obscurity 
also surrounds the origin of organic diseases. 

Observation shows us that, in some persons, one organ is much 
more frequently affected than the rest, or is even the exclusive 
seat of almost all the diseases which manifest themselves during 
an entire life, or at any rate, during one or more of its great divis- 
ions, as infancy, youth, or adult age : in one individual the lungs, 
in another, the stomach or intestines, in a third the brain, are, in 
popular terms the feeble organs, that is, the most liable to the 
action of morbific causes. The advocates of the theory of irrita- 
tion proposed to call this tendency of an organ to become diseased 
diathesis, * and they admit pulmonary, gastric, cerebral and 
uterine varieties ; but with most authors and in the usual language 
of science, this word has a different acceptation. Diathesis is a 
disposition through whose influence many portions of the body, 
either simultaneously or in succession, become the seats of spon- 
taneously developed affections, identical in their nature, although 

* Jiudtaig, disposition. 



60 ETIOLOGY. 

variable in external appearance. Consequently, as many sorts of 
diathesis must be admitted, as there are diseases which show 
themselves in various organs simultaneously or otherwise, by the 
agency of a common internal cause : this latter condition is barely 
admissible. If various forms of inflammation, as peritonitis, 
pneumonia and ophthalmia, should occur simultaneously in the 
same patient, each arising from evident external causes, there is no 
existent diathesis ; but if these affections are developed without 
distinct cause, they are then attributed to a common predisposition, 
styled inflatwmatory diathesis. — Rheumatic, gouty, tuberculous, 
cancerous, gangrenous, herpetic, scorbutic, osseous and aneurismal 
diatheses, have been admitted ; to these, the varicose, melanic, 
ulcerative and hsemorrhagic should be added. 

The simultaneous development in many parts of the system, of 
rheumatic or gouty affections, of tubercle, cancer, gangrenous 
disease, herpetic eruptions, scorbutic symptoms, osseous and 
aneurismal tumors, varix, melanotic deposits, ulcers, granulations 
and haemorrhage declares the existence of the corresponding 
diatheses. We admit also a granular diathesis which most physi- 
cians regard as a variety of the tubercular. Some authors mention 
a dropsical diathesis, which is incorrect, since dropsy is in general 
merely a symptom. The mucous and bilious diatheses are too ill 
defined for retention among scientific terms. Finally, we do not 
allow the purulent diathesis of some writers, because it is most 
frequently a mere infection ; nor a syphilitic or variolous diathesis, 
because these diseases do not recognise an internal cause, but are 
owing to the evident absorption of a virus whose mode of action 
is wholly unlike that of diathesis. 

A peculiar disposition exists in a few instances, which, either in 
the exercise of some function, or in the impression made upon it 
by external agents, produces phenomena wholly different from 
those which are observed in most persons in similar circumstances; 
such are the syncope caused by the sight of certain objects, or by a 
kneeling posture maintained for some time ; and the urticaria noticed 
in some individuals whenever they take certain food, as strawberries 
and shellfish. There are persons upon whom exposure to the exter- 
nal air has uniformly the same effect during the cold season. Bovr- 
dier saw at the Hotel Dieu of Paris, a man forty years of age, 
become affected with intermittent fever whenever elastic bougies 
were introduced into the urethra.* An exceptional predisposition 
must universally be admitted, through whose agency, in certain 
persons, like causes always produce remarkable effects. This is 
called morbific idiosyncrasy. 

Predisposing and individual causes may act in unison or singly. 
Their energy is in proportion to their mutual action, or tendency 
to modify the economy in a similar manner. 

Among a large population, the individual rarely agree with the 
general predispositions, from which it results that all the inhabi- 

* 77ieses de la Faculti de Medecine de Paris, annie 1809, No. 17. 



ETIOLOGY. 61 

tants of a district are very seldom simultaneously attacked by 
disease, except it spring from a contagious principle, that is, a spe- 
cific cause acting independently of predisposing causes. An affec- 
tion uniformly developed by the latter, hardly ever attacks more 
than one third or one quarter of a population ; most usually 
only one tenth, one twentieth, or even a less proportion. We 
can sometimes be certain, that those attacked by the prevailing 
malady, are those in whom the influence of general predisposing 
causes has rendered more active that of the individual pre- 
disposing causes. When, for instance, bilious affections are very 
common, persons of bilious temperament, who live chiefly on 
animal food, etc., are more often attacked, while the sanguine or 
lymphatic, being less impressible by general predisposing causes, 
possess a resisting power in their very constitution. Thus, other 
things being equal, the latter are more rarely and less severely 
affected, while the former are more generally attacked and with 
more violence and rapidity. There are, however, many excep- 
tions to this rule. 

1. Individual predisposing causes are sufficient of themselves to 
produce most diseases. There is no affection which may not be 
occasionally developed in isolated individuals, independently of 
general predisposing causes. Angina and pneumonia, for instance, 
although more frequent in certain seasons, may occur in all, through 
the influence of individual predisposing causes only. Often, while 
certain diseases prevail under the influence of general causes, indi- 
vidual predisposing causes develope affections of a wholly different 
nature. It is in this way that inflammatory diseases may appear 
in certain persons inhabiting places where dropsy and scurvy are 
endemic. 

2. On the other hand, general predisposing causes, when exceed- 
ingly active, may exert an influence independently of the individ- 
ual predisposants, and even notwithstanding the resistance they 
offer. Thus it is that diseases developed during public calamities, 
as famines, sieges, etc., fall upon all classes of society, almost 
without distinction ; neither is any temperament or age exempted, 
as has been observed in many epidemics, particularly at Modena* 
and Naples, f 

As regards their relative energy, then, we find that general pre- 
disposing causes may neutralize the effect of individual causes, 
and bring on diseases entirely in opposition to the latter, and vice 
versa. 

Before concluding what we have to say of predisposing causes, 
we remark, that if there be certain conditions which dispose to 
disease, there are likewise many which are preservative of health. 
Without mentioning in this connection that unknown power called 
vital force, which, as has been said, appears to struggle incessantly 
against the destructive agents which surround us, there are condi- 

* Ramazzini, 1690-93. 
f Sarcone, 1764. 

6 



62 



ETIOLOGY. 



tions which exempt us from certain affections ; habit, in particular, 
is one of these. By it the most indigestible articles of food are par- 
tially deprived of their injurious effects, and the pernicious energies 
of the most subtle poisons destroyed ; the Turks use opium with 
impunity, and Mithridates, according to historians, became insen- 
sible to poisons. We must not suppose, however, that the daily 
use of deleterious substances has no injurious effect upon the econ- 
omy ; habit does not wholly free us from their action ; it merely 
alters and strikingly enfeebles it. 

The power of certain contagious principles seems to be exhaust- 
ted in like manner by the force of habit. In places where yellow 
fever is endemic, the inhabitants are not attacked by it, as at 
Havana and Vera Cruz, for instance. The Turks resident at Con- 
stantinople seem to be as much habituated to the principle of the 
plague, which is in almost continual action in some parts of the city, 
as they are to opium by daily use. We may with as much propriety 
conclude that if the visiting physicians of hospitals are not more 
frequently than others the victims of typhus when widely epidemic, 
it is because they have become accustomed to the action of the 
contagious principle before it has acquired its full power. 

The force of habit goes yet farther, and deprives even chemical 
agents of a portion of their influence over living tissues. There 
are those who handle with impunity bodies at a very high temper- 
ature, as burning coals, or iron bars whose opposite extremity is 
incandescent ; others have accustomed themselves to swallow boil- 
ing liquids without any sensible inconvenience. Tartra relates the 
curious fact, that a woman given to intemperance, had passed 
from the immoderate use of wine to that of brandy, then of alco- 
hol, and even of ether ; at last, unaffected by these liquids, she fin- 
ished by drinking nitric, acid, without experiencing from it any 
remarkable injury.* 

It is hardly necessary to add, that age, sex and temperament are 
all conditions which should be considered preservative against cer- 
tain affections. Primitive scirrhus or aneurism are never observed 
in infancy ; one instance only of croup is recorded in old age. 

We have already seen that some contagious diseases attack the 
same person but once during life ; those who have been affected, 
are consequently exempt. A very extraordinary, although very 
well known phenomenon, is the reciprocally preservative property 
of variola as regards vaccinia, and vice versa. This fact which 
is unique in the history of contagious disease, naturally leads us to 
suspect a similarity of origin in these affections. 

Finally, there exists a fortunate disposition, whose nature is un- 
known, but whose effects are appreciable, which protects from cer- 
tain maladies. There are some individuals who appear to be 
insusceptible of the contagion of variola, or vaccinia. Others ex- 
pose themselves daily to syphilis with impunity. In all the 
instances of epidemic typhus or yellow fever there are some who 

* Empoison, par V acide nilr., p. 124. 



ETIOLOGY. 63 

brave the contagion and escape the disease. When the plague 
was at Marseilles, the venerable Belzunce, patriarch of the city, 
was not affected by it, although almost constantly among the sick, 
aiding them in every manner. In the black plague which deso- 
lated the south of France, in 1347, another fact, no less remarka- 
ble, was noticed ; of thirty-five monks who dwelt in the monastery 
of Mont Rieux, one only escaped the contagion ; this was Gerard, 
brother of the celebrated Petrarch, who took care of all the breth- 
ren and also buried them. 

§ IV. We have considered the mode of action exhibited by spe- 
cific and predisposing causes in developing disease; it remains for 
us to notice that of the occasional causes. The influence of the 
latter is not by any means so great; they act only when there 
exists a predisposition. Thus, of ten persons who may commit an 
excess of the table, or who may be exposed to cold, etc., there 
will be, at farthest, but one or two whose health will be disturbed, 
and sometimes out of a larger number there will be none affected. 
Moreover, these causes have no influence upon the sort of affection 
which is developed ; the same occasional cause may, as we have 
seen, excite any disease, and the same disease may result indiffer- 
ently from any occasional cause. Such a cause is, as it were, a 
shock given to the system ; it does not affect those in firm health ; 
in others it may develope any affection whatever. 

Such is the mode of action of each kind of morbific causes. 
There is a certain number of diseases in whose production some of 
these three classes of causes concur ; there are others where the 
disease arises exclusively from a specific cause, or from one or 
more predisposing causes. Asphyxia always depends on a specific 
cause ; typhus requires the influence of some predisposing cause in 
the majority of cases ; and sometimes an occasional cause, as ter- 
ror, or too strict diet, may excite its attack ; plethora and inflam- 
matory fevers are almost always exclusively produced by predis- 
posing causes ; no affection arises solely from an occasional cause. 

The knowledge of causes is not absolutely necessary in particu- 
lar cases. When the disease is due to specific causes, they are 
easily appreciated, but the predisposing causes, which are usually 
obscure, frequently escape the physician's sagacity. The kind of 
disease developed, may in some cases lead to the suspicion of the 
causes which have produced it, and serve as a guide in the search 
for them ; but in many other instances these causes remain uncer- 
tain, or even unknown. In respect to occasional causes, as they 
are immediately antecedent to the disease, they attract more par- 
ticularly the patient's attention, which cannot fail to instruct the 
physician ; but a knowledge of them is generally of slight impor- 
tance, and many diseases make their appearance without their 
influence. 



64 



ETIOLOGY. 



ARTICLE FIFTH. 

Division of Diseases relatively to the Causes which produce them. 

Diseases arising under similar conditions, or which offer cer- 
tain points of resemblance as respects their causes, have been 
grouped together and possess certain interesting relations. The 
principal groups to which this etiological division has given rise are 
those of innate and acquired, sporadic, endemic and epidemic dis- 
eases. 

By innate or congenital diseases {morbi cognati, congeniti) is 
understood those exhibited by the child at birth. They are not all 
hereditary, neither do all hereditary diseases appear at the time of 
birth. The latter have existed, or are still present in the parents, 
and this does not necessarily occur in regard to the former. An 
affection may be both hereditary and congenital. 

Under the title acquired diseases {morbi acquisiti, adventitii) 
are included those not commencing till after birth and independent 
of hereditary disposition. All diseases may come under this head 
except deformities. 

Sporadic diseases {morbi sporadici*) are those which attack a 
single individual, or a certain number of isolated persons. They 
depend especially upon the predisposing causes ; for the epithet 
sporadic is not given to affections induced by specific causes. We 
do not say that wounds, fractures, and asphyxia are sporadic ; 
this term is applicable only to those diseases whose development 
is apparently spontaneous. Sporadic diseases are, of all, the most 
common ; they appear at all seasons, at every age, and in all 
climates, under the action of individual causes. 

Diseases which attack a mass of individuals at once, have been 
styled pandemic {morbi populares); these have been subdivided 
into several series, according to the circumstances which accom- 
pany their development. Those which appear every year at 
nearly the same time, are called annual {morbi annui, anniversarii); 
those which manifest themselves uninterruptedly for many seasons, 
or one or more years, are known as statiotiary {morbi stationarii) ; 
those occurring at various seasons, and modified only by prevalent 
affections, are termed intercurrent {morbi inter cur rentes). At the 
present time these names are generally abandoned, and two classes 
only of popular diseases are admitted, endemic and epidemic. 

Endemic \ diseases {morbi endemici) are those produced by the 
concurrence of causes constantly or periodically in operation in 
certain situations, so that the diseases resulting from them are con- 
stant, or at any rate, appear at fixed periods, affecting, in every 

* Sni ijjw, to scatter here and there, 
f Ev, in ; Sijiiog , the people. 



ETIOLOGY. 65 

instance, a greater or less proportion of the population ; such are 
goitre and cretinism in the Valley of the Rhone, and intermittent 
fever in most marshy districts. 

Epidemic* diseases, (morbi epidemict) which, like the former, 
attack a large number of persons simultaneously, or become far 
more frequent than they usually are, have a limited duration, and 
do not appear at regular intervals. Their causes have ever been 
the object of research to the observing physician. Nearly every 
one is ready to acknowledge that most epidemics do not depend 
solely upon the circumstances which surround the inhabitants of 
an infected district ; and that the action of a succession of causes 
for a variable space of time, has prepared the way for their mani- 
festation, and produced a predisposition which the actual causes 
have only developed or increased. It is also observed in many 
epidemics, that those who have been resident for a short time 
only in the region where they prevail, escape them, while the 
older inhabitants are attacked. Some have sought for the causes 
of all epidemics in the food and drinks, but especially in the sensible 
qualities of the atmosphere. Others having noticed that the changes 
sometimes occurring in the atmosphere during an epidemic, do not 
always sensibly influence its course, have concluded from this, 
that the exciting and continuing causes of prevalent diseases do 
not exist in the appreciable qualities of the air. They have thus 
been led to admit hidden qualities in this fluid, to which they 
attribute the diseases, whose occurrence cannot be explained by 
the sensible changes of the atmosphere. From this arises the doc- 
trine of occult causes, admitted under various titles, by very cele- 
brated and highly judicious physicians, from Hippocrates to 
Sydenham and Mertens. 

Nothing was better suited to throw light upon this question, than 
the numerous epidemic constitutions, published within two cen- 
turies. It was thought that a constant relation would be recognised 
between epidemics and the conditions under which they manifest 
themselves, by means of a careful comparison, for a series of years, 
on the one hand, of the various states of the atmosphere and the other 
general morbific causes ; on the other, of the diseases developed 
under their influence : this is the object of epidemic constitutions. 
The result, however, has not answered the apparently well founded 
expectations formed in regard to this undertaking, either because 
the epidemic constitutions were not properly observed and de- 
scribed, or because epidemics depend upon causes which have 
hitherto escaped our means of investigation. 

Without giving a decided opinion upon so obscure a question, 
we shall remark, that among the hitherto described epidemics, 
there are some which seem to have fixed appreciable causes : of 
thisnumber are those of Lausanne, Modena, Gottingen and Genoa ; 
but we must still remember that a concurrence of causes resem- 
bling those already cited, would not necessarily produce like effects ; 

* Eni, upon ; <5»>os, the people. 

6* 



66 ETIOLOGY. 

and that by far the greater number of epidemics cannot be ascribed 
to any known causes, notwithstanding the great pains that many 
physicians have taken to indicate every circumstance which pre- 
ceded or accompanied their development. 

Among widely prevalent diseases, there is a certain number 
arising from contagion or infection, which must not be confounded 
with the rest, although the majority of writers have included them 
under the common denomination, epidemic diseases. 

It is not always easy to determine whether a disease which 
attacks many persons simultaneously, be owing to general predis- 
posing causes, or to a contagious principle. It may happen * that 
a disease is really contagious while it appears only epidemic, 
because contagion does not affect all who are exposed to its in- 
fluence, or because the vehicles of contagion and the contagious 
principles being almost infinite, persons may be affected who 
thought themselves removed from all communication with the 
sick ; and again, some other affection, considered contagious, be- 
cause it attacks individuals who are in communication, may be 
dependent upon epidemic influence, which is common to all. 
Thus when many persons occupying the same house, fall ill si- 
multaneously or successively, contagion is nearly always suspected ; 
yet, as Ramazzini^ remarks, it is natural that a number of per- 
sons exposed equally, and for the same length of time, to the 
influence of the same causes, should be attacked, at a nearly 
identical period, with the same disease. A sort of maturity, says 
this distinguished physician, supervenes in the system when 
exposed for a certain time to the action of similar morbific causes. 

In certain instances, the difficulty of lulling all suspicion of 
contagion, hinders us from wholly denying its action ; and in others 
we cannot admit it, from not being sure whether the disease is 
ascribable to the state of the atmosphere, or to some other general 
cause. 

The more volatile and easy of transmission the contagious prin- 
ciple, the more obscurity surrounds it. 

Another circumstance which renders the distinction more difficult 
is, that the majority of contagious diseases attack a population only 
while contagion is favored by a peculiar condition of the atmos- 
phere, or by other general predisposing causes to which the 
prevailing malady might be attributed. Finally, contagion some- 
times loses its activity after a time, and from observations at such 
periods, we are led to suppose that the affection is not contagious. 
This has been remarked in most of the pestilential diseases, par- 
ticularly in the typhus of Europe, and the plague of the East. 
We should find it difficult to conceive of their gradual cessation, if 
this principle be not admitted. 

There are, nevertheless, certain circumstances which serve to 
distinguish contagious from epidemic diseases : among these are 
inoculation and importation. Whenever a disease is clearly capable 

*Tommasini. Fihvre jaune. f Epidem. Modlne. 



ETIOLOGY. 67 

of transmission from the affected individual to the healthy, and 
this transmission has been recognised in repeated instances, con- 
tagion can no longer be doubted. It is in this manner that the 
contagious nature of variola and vaccinia has been clearly proved. 
The impossibility of transmitting a disease by inoculation, has 
been considered a negative means of forming an opinion as to 
contagion. During the prevalence of epidemic cholera, many 
courageous and devoted physicians inoculated themselves with the 
matters excreted by the sick, with the intention of throwing light 
upon this question, whose solution was so important to society. 
While we award to their zeal the praise due to the honorable 
motive which directed them, it must be asserted that these experi- 
ments were not sufficient to fully settle the question. All diseases 
are not similarly contagious ; many have a peculiar mode of trans- 
mission, out of whose limits contagion does not manifest itself. 
Thus syphilis is rarely contracted except by coitus; nor the 
vaccine disease, except by the artificial insertion of the liquid 
contained in the pustules. The same may be true of certain other 
affections ; and the virus of Asiatic cholera, if it exist, might 
require, in order to transmission, a different mode of inoculation 
from those hitherto tried. In addition, as we have elsewhere 
remarked, every individual is not prone to receive the contagion ; 
many more cases, also, are needed, in order to solve the question, 
and in trials of this kind, negative have far less influence than 
positive results. Finally, it should be remarked, that the develop- 
ment of a disease in those who have been subjected to inoculation, 
cannot prove its contagious nature, except the inoculation be prac- 
tised at a distance from the place where the affection prevails. 
Thus, whatever may have been the results of inoculations which 
took place during the epidemic cholera, and in the regions where 
it raged ; they were, from the very first, of no value. 

Importation, is, in this class of cases, the most suitable means 
of explaining these questions. When a disease previously un- 
known in a country, suddenly makes its appearance there ; if its 
manifestation succeed the arrival of a number of strangers who 
may be then affected with it, but recently cured, or who come 
from a place where it prevails ; if those who receive these strangers 
and provide for them, are the first to be attacked by the disease ; 
and if it next appear among the individuals who live with those 
first affected, it is evidently contagious. It is in this manner that 
the appearance of variola at the (Jape of Good Hope, in the Faroe 
islands and in many parts of Russia, where it was previously 
unknown, would prove, if it were necessary, the contagious nature 
of this disease. The importation of scarlatina into Podolia,* as 

* Hildenbrand thus speaks in regard to this subject : " A black coat which I 
wore when visiting a patient affected with scarlet fever, and afterwards carried 
with me from Vienna into Podolia, without having it on for the space of one year 
and a half, communicated to me this contagious disease upon my first arrival ; 
from me it spread in the province, where it had until then been almost unknown." 
— (Du Typhus Contagieux.) , 



68 ETIOLOGY. 

related by Hlldenbrand, establishes, in like manner, its contagious 
qualities. If the importation of the plague, of yellow fever, or of 
Asiatic cholera were absolutely proved, it would leave no doubt as 
to the contagious nature of these diseases. But in the present 
state of our knowledge, these delicate questions are yet undecided. 
Many good observers are convinced that these diseases, arising in 
the first place from miasmata, are transmitted more particularly 
by the accumulation of the sick ; and that consequently they are 
infectious. It should be added, that any disease arising from a 
crowding of patients, and infectious in its origin, may become 
contagious in its future transmission. Camp fever and hospital 
gangrene are striking examples. 

Upon this subject we shall offer one final remark, viz. It is not 
in large cities that the question of contagion can be advantageously 
studied and thoroughly examined. In a place where six or eight 
hundred thousand inhabitants are congregated, unknown to each 
other, it is impossible to follow in its transmission, the most evi- 
dently contagious disease. The course of variola at Paris may be 
cited as an example, and the impossibility of arriving, in the ma- 
jority of cases, at a knowledge of the period and source of its trans- 
mission. On the other hand, in places where the inhabitants are 
fewer and better acquainted, it is usually easy to follow the 
propagation of a disease ; all know who were first attacked by it, 
what other persons have been successively affected, and what com- 
munication they held with those first diseased. On this account, 
villages, and not populous cities, are the places where the mode 
of propagation of diseases can be advantageously studied, and 
their contagious, infectious, or merely epidemic character, most cor- 
rectly appreciated. We do not, in this connection, speak of 
syphilis or vaccinia, which cannot be confounded with epidemic 
diseases, since they require close contact in order to their trans- 
mission.* We shall conclude by calling to mind this ancient 
precept, too often combatted in our day, that whenever there is 
uncertainty in regard to contagion, it is the physician's duty, as 
also that of the acting authorities, to proceed as if it were proved. 
There is, doubtless, serious inconvenience in declaring contagion 
to exist where it does not in reality, but there is still greater in 
mistaking it when really present, f 

* According to many authors, (and the opinion is supported hy certain histo- 
rical facts,) it would appear to be proved that syphilis, at the period of its first 
appearance, presented as ready a contagion as the plague or variola, and that, in 
course of time, it became less and less active. No other contagious affection 
has presented analogous changes in its mode of transmission. 

f This motive would have sufficed to induce us to rank yellow and typhus 
fever among the contagious diseases, even if we had not been convinced, as we 
are, of their contagious nature. [The author ranks himself with the very small 
number of those in favor of the contagious nature of yellow fever : the best 
ohservers of the present day are decidedly opposed to the doctrine of contagion. 
Grisolle, in his work on Internal Pathology, 1 makes several assertions which 

1 Path. Int., Vol. i, p. 77, Deuxi^me Edition. De La Fi&vre Jaune. 



ETIOLOGY. 69 

Diseases have likewise been divided, in respect to their causes, 
into essential, primitive, or protopathic* and into symptomatic, 
secondary, or deuteropathic.\ The first are the immediate result 
of morbific causes ; the second depend upon another affection, of 
which they are, properly speaking, but a symptom. Haemorrhage 
belongs occasionally to the latter, sometimes to the former. They 
are essential, when not connected with perceptible lesion of the 
organ where they are seated ; they are symptomatic in scorbutus, 
and many organic affections. 

It is sometimes easy to determine, whether a disease is primitive 
or secondary : thus, when cancer of the uterus has attained a 
certain stage, the sanious discharge cannot be mistaken for uterine 
catarrh, and the haemorrhage, which comes on at intervals, can- 
not be considered as primitive ; but it is otherwise when the 
same disease is only commencing, and the neck of the uterus 
does not yet present the hardness and deformity which character- 
ize the disease. 

There is a certain number of affections which, however well 
marked they may be, are essential according to some authors, and 
are considered symptomatic by others ; among these are curva- 
ture and softening of the bones, regarded by some physicians as 
primitive diseases, while others look upon them as secondary, and 
connected with scrofula. The intestinal ulcerations in typhoid 
fever, and the enlargement of the spleen in intermittent fever, are 
likewise of this class. Dropsy and the neuroses have been, and still 
are, at least in some of their forms, subject to similar diversity 
of opinion. Exact observation and thorough discussion have 
decided some of these questions, and time will gradually lead to 
the solution of many others. 



ARTICLE SIXTH. 

Lapse of Time between the Application of Causes and the Development 

of Disease. 

A certain number of diseases are produced at the moment 
when the action of their determining cause takes place; this is 

seem sufficiently positive in regard to the truth of the opinion of the non-con- 
tagionists ; he mentions the names of Chervin, Dalmas, Deveze, Valentin, and 
Rush, as among the principal supporters of the latter doctrine. The work of Cher- 
vin is pronounced by the accomplished editors of the American edition of Marshall 
Hall's Theory and Practice of Medicine, to be the most elaborate investigation 
of the point in dispute ; ' and certainly, if we consider the time devoted to his 
undertaking, and his unwearied researches both in Europe and America, his 
opinion is entitled to our very highest consideration. Five hundred Spanish 
and American physicians out of six hundred, coincided with him in favor of 
non-contagion. — Trans.] 

* I7u6oc, disease ; i'dioc, proper; noonog, first. 

f Ilu&oq, disease ; devrtQog, secondary. 

1 Prin. of the Theor. and Practice of Med. By M. Hall. American Edition, p. 275. 
Yellow Fever. 



70 PRECURSORY PHENOMENA. 

observed in contusions, wounds, fractures, and the inspiration of 
certain deleterious gases. The inflammation resulting from the 
application of rubefacients is usually manifested in a short time, 
as an hour, for instance ; the action of vaccine virus commences 
at the end of three days ; the first symptoms of variola are not 
evident, generally speaking, till eight days from the period when 
the contagion took place ; syphilis is not developed in some in- 
stances for three or four weeks after connection, and usually the 
first symptoms of rabies do not declare themselves in adults be- 
fore the thirtieth or fortieth day after the bite. 

The time which elapses between the application of contagious 
principles and their first effects upon the economy, has by many 
authors been called the period of incubation. 

It is almost always impossible to ascertain accurately the time 
since which the predisposing causes have acted : some of these 
causes are inherent in the constitution of the individual, as age, 
sex, temperament, etc. The development of disease follows im- 
mediately, or at any rate, very closely, the application of occa- 
sional causes. — M. 



CHAPTER VI. 

PRECURSORY PHENOMENA. PRELUDES. ANTECEDENT SIGNS. PRO- 
DROMES OR IMMINENCE OF DISEASES. 

All those phenomena which are exhibited from the moment 
when the healthy action of the functions begins to be disturbed, 
up to the time when the disease commences, are styled precursory 
or antecedent signs.* 

Diseases are not invariably ushered in by precursory phenome- 
na ; the transition from perfect health to illness may be sudden. 
Those affections which are produced by specific causes never have 
any prodrome, even when they arise from contagion. The sneezing 
which precedes the eruption of rubeola, the vomiting which occurs 
previously to that of variola, cannot be considered as precursory 
phenomena ; they are the first effects of the action of the peculiar 
virus of these two affections, and the disease has already com- 
menced, although the eruption be not apparent. Preludes do not 
take place, except the affection be owing to predisposing causes; 
none are observed in chronic diseases. 

The precursory phenomena have not, generally, any analogy 
with the malady about to be developed, and cannot lead us to sus- 
pect its nature. Those of almost all diseases strikingly resemble 

* IZq'o, before ; tybfios, course. 



PRECURSORY PHENOMENA. 71 

each other, and those of the same affection are scarcely ever simi- 
lar. When, however, an epidemic prevails, it may be announced 
by phenomena which are uniform in a large majority of cases, and 
from this the physician recognises, or at least suspects, the kind of 
affection about to appear. But, in most instances, the prodrome 
cannot lay the foundation of any decision, nor even of reasonable 
conjecture. 

The precursory phenomena of acute diseases are exceedingly 
varied and numerous. We shall mention those most usually ob- 
served. 

The attitude indicates an unusual languor, the step loses its or- 
dinary firmness, there is progressive loss of flesh, the expression of 
the countenance is slightly altered, in a manner appreciable only 
by those familiar with the individual ; the face is either pale, or 
pale and flushed alternately; the least exercise causes fatigue; 
slight flying pains, variable in their seat and nature, are experien- 
ced in different parts of the body, particularly the head ; transient 
disturbance of the senses of sight and hearing occurs, as dimness 
of vision, and tinnitus aurium; the moral impressions are either 
increased or diminished ; presentiments of misfortune and inability 
for mental exertion, disturbed sleep, its entire absence, or a slight 
degree of somnolence, are frequent precursory phenomena of dis- 
eases. The appetite is usually diminished, rarely heightened or per- 
verted ; the mouth is often clammy or bitter, the thirst increased, the 
breath fetid, digestion difficult and slow, and the bowels less regular. 
The slightest exertion causes breathlessness ; at intervals, sighing, 
groaning, yawning, stretching, and occasionally, repeated fits of 
sneezing are noticed. Palpitation, syncope, sensitiveness to exter- 
nal cold, the unequal distribution of heat, a dry skin or transient 
perspiration, a paler or deeper color of the urine and inaction of the 
genital organs, announce the approaching invasion of an acute af- 
fection. 

In other cases, illness is preceded by entirely opposite phe- 
nomena; the functions, far from being enfeebled, seem exercised 
with more than ordinary vigor ; the countenance is flushed, the 
strength increased, the intellectual faculties more active, appetite 
and digestion are more powerful ; the individual congratulates 
himself upon his increased health, which is but a precursor of 
disease. 

Certain other phenomena have been observed while disease was 
still latent ; one patient experiences a sensation which may be 
compared to that caused by a breath of wind lightly fanning the 
surface of the body; another, a sort of shock similar to that caused 
by electricity. Finally, to these phenomena should be added the 
changes supervening in the pre-existing diseases, in the secretion 
from wounds or ulcers, cauteries, blisters, in the appearance of ex- 
anthemata, etc. It is not uncommon to observe at such times a 
more or less complete absorption of the serosity infiltrated into the 
cellular tissue. 

Such are the principal phenomena which precede acute diseases. 



72 SYMPTOMS. 

They may be variously grouped and combined. Each of them 
may exist separately. They are never all present in the same in- 
dividual. 

The duration of the precursory period is very variable : occa- 
sionally a few minutes, sometimes a number of hours ; it may 
continue many days or even weeks, but rarely longer. When it 
has been long, a grave disease may be apprehended, there are, 
however, numerous exceptions to this rule. 

When the intensity of the precursory phenomena augments pro- 
gressively, they may gradually become confounded with those of 
the disease, and likewise with the occasional causes which excite 
its appearance ; a chill, an attack of indigestion, the suppression 
of an habitual evacuation, the desiccation of an issue, are at one 
time the causes, at another the first effects of the disease. 

The intensity of precursory phenomena cannot convey an accu- 
rate idea of the gravity of the affection which they announce. 
The prodrome of some very severe, and even fatal diseases, may be 
hardly perceptible ; while certain mild affections are sometimes 
preceded by inexpressible anxiety and other very alarming signs. 

The same phenomena which precede diseases may be manifested 
without any subsequent illness ; they cease suddenly, or gradually 
disappear, and the functions resume their usual regularity. — M. 



CHAPTER VII. 

SYMPTOMS,* OR SYMPTOMATOLOGY. 

A symptom is any change perceptible to the senses, occurring 
in any organ or function, and connected with the existence of 
disease. 

Symptoms should not be confounded with phenomena or signs. 

A 'phenomenon is any act or change effected in the healthy or 
diseased body, whereas, a symptom is alone observable in the latter. 
Where there is no disease, there can be no symptom. Galen 
justly remarks, that the symptom follows the disease, as the 
shadow follows the body. Hence, the impropriety of the terms 
precursory and consecutive symptoms, employed by many authors • 
whatever is observable previous to the existence, or after the ter- 
mination of a disease, is a phenomenon, not a symptom.f 

It is equally important to distinguish between the symptom and 
the sign. A sign, in the common acceptation of the word, is anv 

* 2w, with, at the same time ; nlmto, I fall, 
f Joyog, discourse ; ovumi<uu, symptom. 



SYMPTOMS. 73 

circumstance, by which we become acquainted with' that of 
which we were previously ignorant. In medicine, is understood 
by this word, whatever reveals anything relating to the past, 
present, or future state of a disease. The causes which preceded its 
development, its mode of attack, its progress, and the effect of 
therapeutical agents, all afford signs as well as symptoms. The 
symptom is simply a sensation, which a special effort of the mind 
is alone able to convert into a sign. While the latter, therefore, 
relates to the judgment, the former is referable to the senses. The 
symptom is recognizable by every one, the physician alone detects 
the sign in the symptom. As there are no symptoms which may 
not furnish some sign to the physician, and moreover, as signs occur 
in health as well as disease, it has been said, that "every symptom 
is a sign, but that all signs are not symptoms." By what means 
symptoms are converted into signs will be seen hereafter : the 
former claim our present attention. 

Symptoms, or the appreciable changes effected by disease in the 
various organs or functions, are very numerous. It is important 
that some method be adopted in their exposition, by means of 
which, those between which the greatest analogy exists, may, as far 
as possible, be grouped together. Several methods have been pro- 
posed, which offer this advantage to a greater or less extent. Among 
these may be mentioned the division into those symptoms appre- 
ciable to the physician, and those perceptible to the patient ; that 
also of Boerhaave, who divided them into three series, according 
as they depend upon disorder of the functions, excretions, or quali- 
ties of the body; and finally, that recently proposed by Bayle, our 
former instructor and friend, who divided them into vital and 
physical: the former, which are solely dependent upon functional 
disturbance without any appreciable organic lesion, and which 
disappear entirely at death ; the latter, on the contrary, which con- 
sist in an appreciable change in the parts themselves, and continue 
after death. It will be at once evident, that this distinction had 
special reference to pathological anatomy, and was entirely inap- 
plicable to the methodical exposition of symptoms. That pro- 
posed by Boerhaave, makes too wide a separation between things 
which are nearly connected ; the secretions, for example, are 
separated from secreted matters, and the qualities of the body from 
the functions to which they belong. 

Another equally important point, is the adoption of some order 
which may be advantageously applied to the history of each 
affection, and to the examination of each particular patient. 
There are many highly commendable practitioners, who at the 
bedside, examine in succession all the functions, the organs of 
which are situated in the head, neck, chest, abdomen, and limbs ; 
this method, which it would be difficult to employ in the general 
exposition of symptoms, would not present in the examination of 
individual patients, the same advantages, which might be obtained 
from a different one. It approximates things the most unlike, and 
widely separates those, between which, the greatest analogy exists. 
7 



74 SYMPTOMS. 

The various disorders of the digestive organs, for example, in- 
stead of being successively and uninterruptedly examined, are 
separated from each other by so many intermediate questions, 
that it becomes difficult to discover the connection between them. 
The same may be said of the circulation and locomotion, the or- 
gans of which extend throughout the economy, and of many 
other functions. 

A more natural method is to examine successively all the de- 
rangements which each function presents, in whatever part of the 
body the organs which concur in its performance are situated. 
This method, which is equally convenient in the examination of 
the patient, and in making a record of the disease, is the only one 
applicable to the particular description of each affection, and to a 
general exposition of symptoms. 

But what order should be pursued, in the examination of the 
functions ? It would be desirable if that could be adopted, which 
is generally followed in the study of physiology ; examining in 
succession the functions of assimilation, those of relation, and 
lastly, those of generation. As, however, this division does not 
present the same advantages in the study of the diseased, as in 
that of the healthy body, we think it unnecessary to confine our- 
selves strictly to it. 

That which strikes the physician, in first accosting a patient, 
and from which he draws his first conclusions respecting the na- 
ture of his disease, is the physiognomy, attitude, movements, and 
voice : here, then, we should naturally commence our examination 
of symptoms ; it is, moreover, at this time that the changes which 
have taken place upon the exterior of the body, are more justly 
appreciated. If this first sensation be neglected, the eye gradu- 
ally becomes accustomed to whatever is unusual in the physi- 
ognomy of the patient, and the physician is rarely able, after re- 
maining with him for a time, to judge with the same accuracy as 
he would have done at first. The same is true of the movements 
and voice ; it is therefore better to commence the examination of 
patients, and the general exposition of symptoms, with the functions 
of relation, afterwards passing successively to those of assimila- 
tion and generation. We shall pursue the following order, in the 
exposition of the symptoms which belong to each of these three 
great series. 

1. Exterior of the body. 2. Digestion. 

Locomotion. Respiration. 

Voice and speech. Circulation. 

Sensations. Heat. 

Affective functions. Secretions. 

Intellectual functions. 3. Generative functions in the male. 

Sleep and the waking state. Generative functions in the female. 



SYMPTOMS. 75 

ARTICLE FIRST. 

Symptoms furnished by the Functions of Relation. 

In order to the just appreciation of the changes effected by dis- 
ease in the various functions, and particularly those of relation, it 
is important, if not indispensable, that the physician be familiar with 
the physiognomy, attitude, gestures, and voice of persons in health. 
Without this fixed point of comparison, he will be unable to 
arrive at more than approximate results, in his appreciation of the 
phenomena which fall under his observation. 

SECTION FIRST. 

Symptoms furnished by the Exterior of the Body. 

The symptoms which may be presented by the exterior of the 
body, are of the highest importance. Having first considered 
those presented by the body as a whole, we shall pass to the 
consideration of those which may be furnished by each part re- 
spectively. 

§ I. The exterior of the body, considered generally, comprises the 
attitude, volume of the body, firmness of the flesh, color of the 
skin, eruptions, plicatures. tumors, and solutions of continuity of 
every kind. To these might be added, the heat and moisture of 
the skin, pulsations of superficial arteries, distension of veins, 
&c. ; but these will be more naturally considered elsewhere. 

A. In health, the attitude in the waking state is free and un- 
constrained ; during sleep, the limbs are usually demiflexed, and 
the body inclined to one side, commonly the right. In disease, 
the attitude varies more or less from these conditions. 

If the patient be up, an unusual degree of languor is observable 
in his attitude; in some cases, as in maniacs, for example, an 
unnatural degree of strength and assurance is noticed. There are 
some diseases which are at once recognizable from the position 
of the patient ; as catalepsy, for example, from the general immo- 
bility ; St. Vitus' dance, from the irregularity and continual suc- 
cession of motions; hemiplegia, from distortion of the features, 
and a change in the position and motions of the limbs, and 
opisthotonos and emprosthotonos, from the convulsive flexion of 
the body backward and forward. 

When in bed, some patients assume various postures, and retain 
them for a time ; others are constrained to remain in the same 
position, a symptom not without importance. Thus some patients 
lie constantly upon the back, (decubitus dorsal) either from debil- 
ity, which occurs in adynamic fevers, or from difficulty or pain 



76 SYMPTOMS. 

experienced when in any other posture, as is the case in general 
rheumatism, and acute peritonitis. Others, from the nature and 
violence of their pains, are compelled, at least for a time, to lie 
upon the abdomen, as in saturnine, nephritic and hepatic colic, and 
in some cases of delirium. At times the patient lies upon one and 
the same side, (decubitus lateral) in consequence of effusion into 
one of the pleurae, inflammation of one lung, or an acute pain on 
either side; in cases of effusion or hepatization the patient lies 
upon the affected side, and upon the opposite side when suffering 
from acute pain. There are however numerous exceptions to these 
rules, the dorsal decubitus being the posture most frequently 
observed in cases of pleuritic effusion, and single pneumonia. 
Lastly, in certain thoracic affections attended with difficulty of 
respiration, and particularly in cardiac aneurism, in double hydro- 
thorax, and in the paroxysm of dyspnoea occurring in pulmonary 
emphysema, the patient is compelled to sit up in bed, it being 
impossible for him to retain the horizontal position ; he is even in 
some cases obliged to bend forward, in order to create a support, 
allowing the legs to hang down. In some affections of the air 
passages, the patient retains the sitting posture, with the head 
thrown backward. In compression of the trachea by a tumor, 
particularly if it be an aortic aneurism, the patient is constrained 
to assume a fixed and often strange attitude, this position doubtless 
partially relieving the pressure upon this organ, and thereby 
rendering respiration less difficult. In other diseases, instead of 
being constantly confined to one position, the patient is obliged to 
change it continually. This state of restlessiiess (inquies) is par- 
ticularly observable in inflammations of the abdomen, and at the 
commencement of eruptive fevers. 

B. The body becomes increased or diminished in volume in 
many diseases. 

A slight increase of volume occurs in febrile heat, and in the 
second stage of intermittent fever ; while in the first or cold stage 
diminution takes place. Plethora produces an analogous effect, 
appreciable in the face, hands, and particularly the fingers, which 
are with difficulty flexed. A more marked tumidity occurs at the 
commencement of the exanthematous diseases. But where con- 
siderable increase of volume exists, it is almost always owing to 
an accumulation of fat or serous fluid in the cellular tissue, and 
is sometimes caused by the passage of air between its lamellae. 

The accumulation of fat, and the consequent increase in the 
volume of the body, have been rarely observed in disease. They 
may occur in certain local affections, which compel the patient to 
abstain from exercise, and in which a subjection to regimen is 
unnecessary. This accumulation, when considerable, is itself a 
disease, which has been designated by the term adipose polysarcia. ■ 

Increase in the volume of the body when occurring in disease, 
is almost always owing to infiltration of serum into the interstices 
of the cellular texture. This infiltration, when general, is called 



SYMPTOMS. 77 

anasarca * or leucophlegmasia, f and when partial, oedema. % It 
is known by the paleness and semi-transparency of the skin, and 
by its pitting on pressure of the finger. This depression however, 
to be perceptible, often requires that the finger be passed lightly 
over it, when it is at once felt. (Edematous swelling may be 
more easily recognized, when the disposition of the skin allows us 
to pinch it between the fingers. Incipient oedema may be often 
thus distinguished in patients confined to their beds, on the inter- 
nal surface of the thighs ; in those who are up. oedema first shows 
itself around the malleoli, particularly towards evening. 

The infiltration of air into the cellular tissue, is called emphyse- 
ma. || It occurs in penetrating wounds of the thorax, and in 
diseases in which the continuity of the air passages is destroyed : it 
is owing in both cases to the introduction of air into the interstices 
of the cellular texture. That which occurs in gangrenous affec- 
tions seems to depend upon the rapid decomposition of parts 
already deprived of life. The insufflation of air into the cellular 
tissue produces artificial emphysema. Can we admit with some 
authors, the existence of spontaneous emphysema, produced by 
exhalation of gas into the cellular tissue 1 Without pretending to 
assign a limit to possibilities, we are of opinion that in the present 
state of the science, such exhalation cannot be certainly proved. 
Emphysema, whatever be its origin, is easily recognized, particu- 
larly in gangrenous diseases, by the crepitation produced by pres- 
sure upon the tumified parts, by the softness and elasticity of the 
distended integuments which readily yield under the finger with- 
out preserving the impression, and by increased resonance. 

Diminution in the volume of the body is a very frequent phe- 
nomenon in disease. It may in the course of a few days, and 
even a few hours, become considerable, as after one or two 
paroxysms of malignant intermittent fever, or after excessive 
alvine discharges, as was observed by Morgagni on his own person, 
in an attack of serous diarrhoea, and as we have ourselves frequent- 
ly remarked in Asiatic cholera; but it usually takes place slowly, 
constituting emaciation, which may exist in different degrees from 
simple emaciation, to marasmus. § In most acute diseases, there is 
little diminution of volume, unless they be prolonged or accompa- 
nied with abundant evacuations, or treated by artificial evacuants, 
as bleeding, purgatives, &c. With these exceptions, emaciation 
does not become very apparent in acute affections till the period of 
convalescence. It is particularly in chronic diseases that it be- 
comes considerable, and in such cases is always indicative of great 
danger. 

C. During the period of growth, in the course of acute and 

*>A*a, in ; ffooE, flesh. 

■J- Jtvxos, white ; <f**y,«a0ia, inflammation. 

t OtSr^ia, swelling. 

|[ 'Euipvoauy, I inflate. 

§ MaQaivu), I dry up. 



78 SYMPTOMS. 

chronic diseases, increase in height is sometimes observed to be far 
more rapid than ordinarily takes place in health. This sudden 
growth is generally a suspicious sign. 

D. The firmness of the flesh demands attentive consideration 
in diseases. Huxham, and many other distinguished physicians, 
have attached due importance to this symptom, with reference to 
the appreciation of the strength, in acute diseases. It is preserved 
and even augmented in most inflammatory affections; and is sen- 
sibly diminished in diseases of debility. Flaccidity of the flesh is 
particularly noticed in the adynamic diseases. 

E. The color of the skin varies according to the climate, sex, 
age, habitual occupations, &c. ; there is however a tint peculiar to 
health which is familiar to every one. There are some slight 
affections in which the color of the skin remains unchanged ; but 
in nearly all grave diseases, there is a perceptible change in the 
natural color of this membrane. 

The skin is pale in the cold stage of intermittent fevers ; and in 
cases of scrofula, chlorosis, anemia and in certain species of dropsy, 
it also has a semi-transparent appearance. It is sallow and en- 
crusted, as it were, with an earthy substance in adynamic diseases, 
particularly in the last stage of grave and epidemic dysenteries, 
and often also in phthisis pulmonalis. It becomes of a livid hue 
in persons of full habit when chilled, in scurvy, diseases of the 
heart, and certain chronic inflammations of the intestinal canal. 
In most of these affections the lividity is more apparent in some 
parts than others, as about the lips, eyes and fingers. The skin 
is of a rosy hue in inflammatory fevers, and just previous to the 
development of general eruptions, it is of a bright red color in 
scarlatina. It presents a yellowish tint in certain bilious affec- 
tions ; is of a dull yellow color in intermittent fevers when of a 
certain duration, of a pale yellow or earthy appearance in cancer, 
and of a citron or deep yellow color in jaundice ; it becomes of a 
bluish tint in those suffering under the severest form of Asiatic 
cholera. The same is observed in certain organic affections of the 
heart; this singular discoloration is caNed cyanosis.* This has 
generally been attributed to malformation of the heart, which 
allows the blood, at least a portion of it. to pass from the right to 
the left side of the heart, without first traversing the lungs. But 
cyanosis is often independent of every such lesion, and even in the 
cases in which there is permanent patency of the foramen Botale, 
it is evident that this affection cannot be referred to admixture of 
the two fluids, as this phenomenon sometimes fails in cases where 
the heart being unilocular, the pulmonary artery and aorta have a 
common origin. Cyanosis seems to depend on a stagnation of 
blood in the capillary vessels, produced by some obstacle to its 
circulation through the lungs and heart ; it is observed in different 

* Kvaio;, blue. 



SYMPTOMS. 79 

degrees, in most organic diseases of this viscus, and particularly 
in contraction of its orifices, in certain forms of pulmonary em- 
physema, and general or capillary bronchitis, and lastly, in some 
cases of rachitis, in which there is considerable deformity of the 
thorax. In these different diseases, cyanosis is generally partial, 
affecting usually the face, particularly the cheeks and lips, the 
hands, principally about the nails and the pulp of the fingers, and 
(in the male) the genital organs, becoming more marked in all these 
parts when general. * We have observed a greenish tint in the 
skin of an anemic patient who appeared to labor under an affec- 
tion of the liver. The skin, in some individuals, accidentally 
becomes, from the influence of some unknown cause, of a blackish 
or brownish color. This was the case with a patient who spent 
several months at the Hospital de la Charite, whose skin, naturally 
white, became almost as black as that of a negro, f Several 
similar cases have been observed and published by M. Rostan. % 

In connection with these cases may be mentioned those, in 
which the blackish or bluish color is owing to a coloring matter 
which transudes through the skin, a very curious example of 
which is given by Billard. || 

Lastly, it is well known that the internal use of nitrate of silver, 
when long continued, produces in the skin a bronze or slate color 
which is indelible. It has been supposed that the light exerted a 
great influence in its production ; but to us this does not appear a 
satisfactory explanation. We believe that light has the prop- 
erty of increasing the color, but is not the sole agent in its produc- 
tion ; for this brown tint appears in parts of the body which are 
shielded from it by clothing, as well as in those parts which are 
exposed to its influence; it is also found to exist in internal organs. 

The skin presents, in some cases, red, black, bluish or yellow 
spots called ecchymoses, which are caused by extravasation of 
blood ; they are often produced by contusions, pressure and other 
external causes ; and are sometimes owing to a cachectic state of 
the system, as in scurvy and morbus maculosus. 

Spots of a livid, brown or blackish tint, are sometimes observed 
in the course of acute diseases, generally appearing upon the most 
depending parts, and constituting an unfavorable sign. These 
spots have been sometimes confounded with ecchymoses, but are 
generally rather the result of stagnation than extravasation of 
blood, as they momentarily disappear under pressure. Eschars 
and excoriations are also formed upon various parts of the surface 
of the body, and particularly those upon which the body rests, as 
the region of the sacrum and trochanters. This phenomenon is 
of more frequent occurrence in typhoid than in other acute affec- 
tions, and its appearance in obscure cases is an important diag- 
nostic sign. 

* Diclionaire de Mrdecine t. ix. Cyanose, par Ferrus ; et Louis Memoires 
anat-pathol., ou Archives de 1823. 

| Bulletin de la Faculte,t. iv., p. 114. 

j Idem. 

\\ Archives de Medecine t. xxvi., p. 453. 



80 SYMPTOMS. 

The skin may undergo modifications of more or less importance 
in disease, which are appreciable to the touch. Instead of remain- 
ing pliant and soft as in health, it often becomes dry and rough, 
as in the first stages of acute affections, and in chronic diseases. 
This roughness and dryness becomes still more marked during 
convalescence from certain eruptive diseases, as rubeola and 
variola. After scarlatina it is dry, smooth and shining, as if cov- 
ered with goldbeater's skin ; this state of the skin which is more 
apparent in the hands, enables the physician, even before desqua- 
mation has commenced, to decide upon the previous existence of 
scarlatina. In Asiatic cholera, the skin in various parts of the 
body, particularly upon the back of the hands and forearms, strik- 
ingly resembles parchment. When pinched between the fingers 
it forms a fold which retains its form for some minutes ; in this 
affection also, the palmar surfaces of the fingers present inequal- 
ities, similar to those which are produced in the same parts, after 
their prolonged immersion in water. 

F. The skin is the seat of various eruptions. These have 
been distinguished by the terms exanthemata, vesicula, bullae 
pustulae, papulae, squamae, tubercula and maculae. Exanthemata 
are reddish spots, with or without prominence, which vary in size, 
form, and degree of color, and which disappear on pressure of the 
finger. Vesicula are small elevations of the epidermis, formed by 
a collection of serous and transparent fluid which sometimes 
becomes opaque. Bullae differ from the latter only in their size, 
which is not less than that of a pea, while vesicles do not 
exceed that of a millet seed. Pustulae are small tumors filled 
with pus, developed upon the surface of the inflamed corpus 
mucosum. Papulae are small hard elevations which contain no 
fluid, but are susceptible of ulceration. Squamae are small laminae 
of epidermis generally thickened, dry, whitish and friable, which 
surmount small elevations resembling papules. The name tuber- 
cula has, in cutaneous pathology, been applied to small, hard, 
circumscribed and permanent tumors, susceptible of ulceration or 
partial suppuration. Maculae are colorations or permanent discol- 
orations of certain portions of the skin, or of the whole cutaneous 
envelope, unattended with general constitutional disturbance. * 

G. Plicatures are impressions made upon the skin by the con- 
tact of bedclothes, or clothing. When occurring in health, they 
are superficial, of a rosy color, and readily disappear. In certain 
diseases, they are deep, lasting, of a livid or bluish tint, and 
sometimes excoriated. Vibices (vibices) are a species of plicature, 
although in some cases they are but varieties of urticaria. 

H. To these symptoms furnished by the exterior of the body, 

* Abregi pratique des Maladies de la Peau, d 'apres leslecons du docteur Bielt 
par Alph. Cazenave et Schedel. 3d edit. 



SYMPTOMS. 81 

may be added tumors, excoriations, fissures, wounds, ulcers and 
fistulas, which may appear on any part of the body. Tumors 
(tumores) consist of a partial increase in the natural size of any 
part ; they vary in form, mode of increase, consistence and in their 
constituent parts. Some disappear under certain circumstances, and 
particularly under the influence of pressure ; others convey to the 
fingers a feeling of fluctuation owing to the presence of a fluid 
which they contain ; others, as certain hemorrhoidal tumors, are en- 
dowed with a kind of erectility. An excoriation is the appearance 
presented by the skin when deprived of its epidermis, and the most 
superficial layers of the corion ; it occurs in grave diseases, and 
commonly precedes the formation of eschars. 

Fissures (fissura) is the name given to those solutions of con- 
tinuity which occur in different parts of the body, and which 
seem by their elongated and narrow form, to result from excessive 
distension of the skin : they are generally owing to syphilitic virus 
or certain eruptions ; they appear on the back of the hand, but 
more frequently at the points of junction of the skin and mucous 
membranes, as about the nose, lips, nipples and orifice of the 
rectum. Ulcers (ulcera) are solutions of continuity depending 
upon some constitutional or local disease. Of these, there are 
numerous varieties according to the elevation of their edges, color 
of the ulcerated surface, and phenomena which generally accom- 
pany them. Fistula are accidental canals which convey away, 
sometimes matters contained in natural canals, and sometimes the 
product of a morbid exhalation. 

§ II. The head, considered as a whole and with reference to po- 
sition and size, furnishes some remarkable symptoms. 

It is inclined laterally in convulsions, paralysis of the muscles 
of one side, torticollis, dislocation of the vertebras and certain 
engorgements of the cervical glands ; it is strongly bent backward 
in croup and in some diseases accompanied by dyspnoea ; it is in- 
clined forward in cases of vertebral malformation. 

The portion of the head corresponding to the cranium is the seat 
of many important symptoms. Its volume is increased in congen- 
ital hydrocephalus. The hairy scalp, when affected with erysipelas, 
becomes oedematous, with extreme sensibility to pressure. These 
two phenomena are particularly important, as the redness, which is 
the principal sign of the disease in other parts of the body, is rarely 
observed in this variety. 

In idiots, the forehead is generally low, narrow and receding ; 
or the occiput may be flattened and directed vertically towards the 
summit of the head. In some cases the two sides of the cranium 
are not symmetrical, one, generally in the parietal region, being 
more or less depressed. The cranium may present tumors which 
are developed either in one of its bones, in the surrounding integ- 
uments, or in the substance contained within it. Its integuments 
are the peculiar seat of certain eruptions, as crusta lactea and tinea. 

The symptoms furnished by the face are extremely numerous, 
of which the most important and difficult of exposition are those 

4 



82 SYMPTOMS. 

presented by the physiognomy. This in health is characterized, as 
has been remarked by Chaussier, by vigor and alacrity, and its 
expression is in harmony with surrounding objects. The various 
shades of expression which the physiognomy is capable of present- 
ing under morbific influence, it would be impossible to describe ; 
it may appear sad, dejected, uneasy, terrified, indifferent or atten- 
tive, sometimes smiling, at others menacing or wandering, without 
there being any circumstance to account for these modifications of 
the features, which consequently should be classed among the 
morbid phenomena. 

The natural symmetry of the two sides of the face is destroyed 
in cases of complete hemiplegia, and in paraiysis of the nerves of the 
seventh pair. The paralyzed side loses all expression, while the 
natural appearance of the sound side is retained ; there is manifest 
deviation of the mouth, its commissures being drawn down and 
towards the median line ; the cheek is flaccid, and the eyelids are 
no longer capable of covering the eye ; the eyebrow is depressed, 
and the forehead free from its natural wrinkles. All these differ- 
ences become still more marked, when the muscles of the sound 
side are strongly contracted, particularly in the effort of laughing. 
If the disease be of long standing, the nose becomes affected. 

Among the numerous alterations of the countenance effected by 
disease, some have received distinctive appellations ; as stupor 
(fades stupida), the injected, pinched, and hippocratic countenance. 
It has also been observed that diseases of the brain, chest, and 
abdomen so modify the countenance as to enable the physician, in 
many instances, to determine from its inspection the seat of the 
disease. 

Stupor is distinguished by a want of expression of the features 
generally, and particularly the eyes; the patient appears uncon- 
scious of what is going on around him, and incapable of reflection, 
as if in a state of intoxication. This expression of face is peculiar 
to typhoid disease. 

The fades vultuosa is characterized by fulness and redness of the 
part, prominence of the eyes, injection of the conjunctivas, disten- 
sion of the eyelids and lips, and fulness of all the features. This 
is particularly observed in hypertrophy of the heart, and in some 
cases of cerebral congestion. 

The pinched countenance, which belongs to acute peritonitis, pre- 
sents the opposite characteristics ; the face appears diminished in 
size, of a pale or livid hue, its muscles contracted, and the features 
drawn upward or towards the median line. Exposure to severe 
cold produces analogous effects in healthy persons. 

The hippocratic countenance has been so called from Hippo- 
crates, who first pointed out its peculiar characteristics. It is 
observable in patients suffering from chronic disease, a few days 
before death, and in some cases of prolonged acute disease. Its 
principal features are the pinched nose, sunken eyes, hollow tem- 
ples, cold and retracted ears, dryness and tensity of the skin of the 
forehead, livid complexion, and cold and relaxed lips ; such are 



SYMPTOMS. 83 

the sure harbingers of death, unless there be some manifest cause, 
as excessive watchfulness, obstinate diarrhoea, or prolonged absti- 
nence, to account for such an appearance. 

Diseases of the head are far from impressing upon the physiogno- 
my uniform characteristics; the same is true of thoracic and ab- 
dominal diseases. There are, however, numerous affections of the 
organs contained within these cavities, in which the appearance of 
the countenance is characteristic. The appearance of sleep, con- 
vulsions of the facial muscles, lateral paralysis, an expression of 
fury or joy, are indicative of a primary, or secondary lesion of the 
brain ; fulness of the face or neck, together with a whistling 
sound in the larynx, or convulsive efforts at deglutition or expec- 
toration, clearly denote some form of angina. There is a peculiar 
alteration in the face noticeable in diseases of the heart, and in 
phthisis pulmonalis, though in the latter it is less apparent. The 
pinched face, as has been remarked, is peculiar to peritonitis, and 
most abdominal diseases of an organic nature are discoverable by 
their effect upon the countenance of the patient. 

M. Jadelot thought he observed in children, a constant corres- 
pondence, between diseases of the head, chest, and abdomen, and. 
certain alterations in the physiognomy, differing from those just 
mentioned. The following, appeared in a work published under 
the supervision of this physician.* In the face of the child three 
principal features are observable ; the first, extending from the 
external angle of the orbit of the eye, to a little below the promi- 
nence formed by the malar bone ; this may be called the oculo- 
zygomatic ; the second commences at the superior part of the 
ala nasi, and embraces in a semicircle, more or less complete, the 
external line of the commissure of the lips ; this is the nasal feature 
to which another sometimes extends, from the middle of the cheek 
called genal ; the last commences at the angle of the lips, and 
terminates at the lower part of the face, which may be called the 
labial feature. The first indicates affections of the brain and ner- 
vous system ; the second and its accessory point out those of the 
abdominal viscera; the third appertains to diseases of the heart 
and respiratory organs, f 

The face furnishes still other symptoms relative to changes in 
its motions, size, color, and the eruptions of which it is the seat. 

Convulsive movements of the face are observed in incipient teta- 
nus, permanent immobility in some nervous diseases, and transient 
tremors in typhus fever ; in some cases of cerebral compression, the 
paralysis is confined to the muscles of this region. 

The face rarely becomes increased or diminished in volume, 
without the occurrence of a similar change in other parts of the 

* Maladies des Enfans d' Underwood, publiees par M. de Salles, avec des notes 
de M Jadelot. 

| We refrain from all conclusions upon the value of these signs ; first, because 
our observations upon this point have been thus far too limited to enable us us 10 
form an opinion ; and second, because the result of these observations would not 
conform to the opinion of M. Jadelot. 



84 SYMPTOMS. 

body ; partial turgescence of this region, however, is common at 
the commencement of eruptive fevers, and sometimes just previous 
to nasal or cerebral haemorrhage. It may be also remarked that 
in those cases in which increase or diminution in volume of the 
whole body occurs, these changes are perceptible in the face before 
"becoming so in other parts. 

In disease, the same changes occur in the color of the face as in 
that of other parts ; it also undergoes modifications which do not 
extend to the rest of the cutaneous surface. Redness of the face is 
a very frequent symptom ; it may affect its whole surface or be 
confined to a particular part. The face is of a bright red color in 
the paroxysms of acute diseases, of a deep and livid red in those 
of hysteria and epilepsy, and the difficulty of distinguishing 
between the two latter affections is partly owing to this circum- 
stance ; in hysteria, however, the face does not present the same 
hideous aspect as in epilepsy, and this, according to M. Landre 
Beauvais, is perhaps the most important sign in the diagnoses of 
these two affections. The face is occasionally the seat of a tran- 
sient redness, commonly known as fenx au visage ; this is partic- 
ularly observable in females suffering from menstrual irregularity, 
or at the critical age. The seat of the redness during the febrile 
paroxysm and in chronic diseases, is the malar region. It is some- 
times confined to one cheek, a phenomenon formerly considered as 
connected with an acute or chronic affection of the corresponding 
lung ; but it generally depends upon the position of the patient 
when in bed, the cheek which rests upon the pillow being redder 
than that of the opposite side. A bright and circumscribed redness 
in the malar regions, together with paleness of the rest of the face, 
is a frequent symptom in tubercular affections. The yelloivness 
which characterizes jaundice is generally perceptible in the face, 
and particularly in the sclerotics, before appearing elsewhere ; it 
also remains apparent in these, after its entire disappearance in 
other parts of the body. In some bilious affections, the yellow 
tint is confined to the labial commissures and alas nasi. 

There are certain eruptions which are peculiar to the face; 
during the period of youth the forehead often becomes the seat of 
a papular eruption which commonly disappears before the age of 
twenty-five. In adults, towards the decline of ephemeral fevers 
and slight acute inflammatory affections, the lips become affected 
with an herpetic eruption. Every part of the face furnishes 
numerous symptoms, which we shall briefly enumerate. 

In health, the eyes are moderately prominent, moist, brilliant, 
moving with facility, and both directed to the same object ; the 
white portion of the eye is smooth, unstriated, and of its natural 
color ; the pupils of both, dilate and contract promptly and equally ; 
the eyelids are thin, moveable, equally separated during the 
waking state, and entirely cover the eye during sleep; the eye- 
brows are slightly arched. Under the influence of disease, the 
globe of the eye and the parts which protect it, present remarka- 
ble changes. 



SYMPTOMS. 85 

The expression of the eyes often corresponds with that of the rest 
of the face : it may be mild, suppliant, threatening, haggard, or ter- 
rified ; but sometimes in the disturbance which accompanies malig- 
nant fevers and the cerebral phlegmasia, their expression is in 
contrast with that of the physiognomy. 

The changes observed in the movements of the eye are generally 
connected with some primary or secondary lesion of the brain. 
The eyes are fixed in catalepsy, and in the ecstasy of melancho- 
lies ; their motions are convulsive in the hydrocephalus of children : 
strabismus or divergence of the optic axes, when occurring acci- 
dentally, is almost always the effect of cerebral disease. 

There is another very remarkable phenomenon, resembling 
ordinary strabismus, but differing from it in some respects ; we 
refer to the isolated movement of one eye, the other remaining 
totally immovable ; we witnessed the repeated occurrence of this 
phenomenon in a case of hemiplegia in a child from ten to twelve 
years of age, succeeding epileptiform convulsions which were 
probably connected with some organic lesion of the brain. This 
symptom, together with a state nearly comatose, had excited fears 
which were not however realized. 

The volume of the eye appears increased in some inflammatory 
fevers, and particularly in cases where an obstacle exists to the flow 
of venous blood in the vessels of the neck, as in severe anginose 
affections and apoplexy by strangulation ; the prominence of the 
eye is lessened, on the contrary, when there is diminution of the 
cellular substance at the bottom of the orbits. The unequal sepa- 
ration of the eyelids may cause an apparent difference in the 
prominence of the two eyes ; but in all these cases their real size 
remains about the same. The size of this organ becomes actually 
increased in internal ophthalmia and hydrophthalmia ; it is dimin- 
ished in the atrophy which follows various diseases of this organ, 
in wounds and after certain operations. It becomes very promi- 
nent, without increase of size, when a tumor is developed at the 
bottom of the orbit, or within the cranium, which presses it out 
(exophthalmia). Inflammation of the cellular tissue of the orbit 
produces a similar effect. The color of the eye corresponds with 
that of the rest of the face ; but these alterations in color are almost 
always confined to the sclerotic and its covering membrane, the 
conjunctiva. Dulness of the cornea is not unfrequently observed 
in acute and chronic diseases a few hours before death. 

The cornea sometimes presents spots of different forms, phlyc- 
tsense, ulcerations, purulent collections, &c, in the diseases which 
are peculiar to it. It may become prominent, the effect of which 
is to increase the refraction of the luminous rays, producing what 
is called myopia ; in other cases it becomes flattened, causing a 
diminution in the refracting power of the eye, and constituting 
presbyopia. 

The motions of the pupil may become variously deranged. This 
aperture is sometimes considerably dilated, although exposed to a 
strong light ; or it may contract slightly and slowly, as in coma- 
8 



86 SYMPTOMS. 

tose affections. In other cases, it is contracted, as in internal 
ophthalmia and meningitis; it is almost always immovable in 
amaurosis, and sometimes becomes of unequal size in the two 
eyes, either from a difference in their natural contractility, or from 
compression of one side of the brain ; its form becomes irregular 
in diseases of the iris. According to M. Jadelot, this irregularity 
also occurs in some verminous diseases. 

The crystalline with its capsule become opaque in cataract ; the 
aqueous and vitreous humors become changed in color in hypo- 
pyon and glaucoma. 

Professor Sanson has recently pointed out a phenomenon, which 
will aid in the diagnosis of many diseases of the eye. If a light 
be placed before this organ, no part of which has been rendered 
opaque by disease, and the pupil of which is dilated either by 
the action of belladonna or in consequence of amaurosis, three 
images of the flame will be distinctly and constantly visible, 
situated one behind the other ; of these, two are upright and the 
other reversed. The most anterior, which is also the most appa- 
rent, is upright ; that situated posteriorly, is the palest and is also 
upright; the third, which is situated between the other two, is 
reversed. The latter is the smallest of the three, being less appa- 
rent than the anterior, but brighter than the posterior, image. 
These three images fail to appear if the cornea be opaque. If the 
opacity affect the anterior surface of the capsule only, the two 
posterior images are not visible ; if confined to its posterior surface, 
the reversed image will alone be wanting. The existence of the 
three images is a certain sign that the crystalline and its capsule 
are perfectly transparent. This new method of exploration in 
diseases of the eye, enables us to distinguish with certainty, in 
some obscure cases, between amaurosis and black cataract, glau- 
coma and the ordinary form of cataract. * 

The parts comprised by Haller in the term, tutamina oculi, 
present in disease numerous alterations. 

Rapid and repeated motions of the eyelids, or perpetual nicta- 
tion (hippus) is observed in some cases of mania and idiocy; in 
other cases, as in adynamic fevers, their motions are extremely 
slow, and occur at long intervals. In cephalalgia they have a 
feeling of weight, as some patients have expressed it ; they are con- 
stantly closed in comatose affections, and in certain cases of 
ophthalmia their closure is accompanied with a violent contraction 
of the muscles ; they remain partially open during sleep, in some 
persons ; in others, during the waking state, they are unequally 
separated on the two sides, as is sometimes observed in hemicrania, 
hemiplegia, and certain acute cerebral diseases. In partial paraly- 
sis, produced by a lesion of the nerve of the seventh pair, closure 

* /,' Experience, No. 1, 1837, t. 1, p. 1, M. M. Bardinot et Pigne, pupils of 
Sanson, have shown by a series of careful experiments performed in the presence 
of the professor, that, the anterior image is produced by the cornea, the middle 
one is reflected by the posterior segment of the capsule, and the posterior one 
by its anterior segment. 



SYMPTOMS. 8/ 

of the eyelids is impossible, in consequence of a partial loss of 
contractility of the orbicularis muscle. The volume of the eyelids 
with that of the neighboring parts, becomes increased in erysipelas 
of the face and in oedema ; the swelling of this part is generally 
more considerable on account of the laxity of the cellular tissue, of 
which its structure is composed ; they sometimes become suddenly 
emphysematous, from contusion at the root of the nose, or after 
violent efforts to blow the nose. In both cases it is owing to a 
rupture of the osseous parts which form the roof of the nose. The 
color of the eyelids generally corresponds to that of the face. Their 
free edges become red and swollen in chronic ophthalmia; they 
become inverted and everted in some diseases of which they are 
the seat. Their adherent borders, particularly of the lower lid, are 
often marked by a bluish line : the eyes are then said to be cernes. 
This phenomenon occurs in many females during menstruation. 
It may however be produced in both sexes by watchfulness, fa- 
tigue, excessive coitus, and excessive evacuations of any kind. 

The conjunctiva becomes more moist and of a deeper red in erup- 
tive fevers, typhus, and particularly in ophthalmia. It is more 
or less swollen in inflammation, and often forms a sort of border 
around the cornea (chemosis). Its natural humidity becomes some- 
times diminished : the eyes are then said to be dry. In some cases 
the mucus which it exhales, forms whitish striae on the globe of 
the eye ; in grave diseases the patient becomes unconscious, and 
neglects to clear it away. 

The caruncula lachrymalis furnishes few important symptoms ; 
it is of a bright red color in inflammatory diseases, and becomes 
pale in chronic affections. Paleness of this little organ is by some 
authors considered as a never failing symptom in dropsy ; but this 
is incorrect. Hairs are sometimes developed on its surface, which 
by contact irritate the eye, and produce obstinate ophthalmia. 

The eyelashes become sometimes covered with dust, and more 
often with scales, in affections of the eye and in severe acute dis- 
eases. Their inversion produces obstinate ophthalmia, and their 
fall is often the result of ulceration of the free edges of the eyelids. 
Their length when considerable has, by some physicians, been 
thought to belong to the tubercular constitution. 

The lachrymal sac becomes swollen, red and ulcerated, when 
any obstacle exists to the passage of the tears into the nasal canal. 
A flowing of the tears over the cheek is often produced by the 
same cause. This latter symptom, called epiphora, may also be 
owing to closure of the puncta and lachrymal canals, and also to 
paralysis of the lids or eversion of the lower lid. 

The eyebrows are raised in the furious delirium of fevers and 
paroxysms of mania, and depressed in cases of melancholy and 
violent cephalalgia. They are alternately elevated and depressed 
during inspiration and expiration, in certain diseases accompanied 
with great difficulty of breathing. These alternate movements 
are sometimes confined to one brow, the other remaining immov- 
able. In paralysis of the facial nerve, the eyebrow of the same 



88 SYMPTOMS. 

side is depressed, and can no longer be drawn towards that of the 
opposite side. 

The forehead in health is ordinarily smooth and serene. It be- 
comes wrinkled in painful and convulsive, and is the seat of a 
papular eruption and exostosis in syphilitic, affections. 

The temples in their natural state are full and smooth ; they 
become concave towards the termination of acute and chronic dis- 
eases. The pulsations of the superficial arteries of this region are 
more manifest in diseases attended with an increased flow of blood 
to the head. 

The cheeks, firm and round in health, and exhibiting more color 
in the malar regions, may become in disease agitated with convul- 
sive motions, or paralyzed ; in the latter case, they are flabby and 
become distended with food in mastication, and with air if the 
patient attempt to blow out a light. One or both cheeks may be 
increased in bulk in odontalgia and certain affections of the max- 
illary sinus. They sometimes become the seat of red and obstinate 
pustules known by the name of gutta rosea, which some physi- 
cians have supposed to be connected with a peculiar affection of 
the liver. 

The nose, which contributes but little to the expression of the 
face, furnishes few symptoms. It has been sometimes observed to 
deviate to the right or left before a convulsive attack, and to 
become red before epistaxis. It is swollen and shining at the com- 
mencement of erysipelas which has not yet extended to the rest of 
the face. It becomes thin towards the close of acute and chronic 
diseases. Its extremity becomes livid and gangrenous in certain 
adynamic fevers, or in consequence of severe cold. 

The nares also deserve attention ; their dilation is rapid and 
convulsive at the moment of respiration in affections accompanied 
with considerable difficulty of breathing; but in cases of extreme 
debility and emaciation they are contracted, as is observed in the 
hippocratic countenance. In paralysis of the facial nerve the naris 
of the affected side is immovable ; and not only is it incapable of 
dilatation during the act of inspiration, but is often depressed. The 
nares are sometimes filled with a blackish mucus in the course 
of grave fevers ; they become the seat of a scaly eruption towards 
the close of some light diseases, and of fissures in scrofulous chil- 
dren. Tumors developed in the nasal fossae may be seen in the 
interior of the nares, and in some cases they protrude beyond these 
openings. 

The lips in healthy persons are free and supple in their motions ; 
when at rest, they are closed, firm and sustained by the action of 
their muscles ; their borders are smooth, rounded, and of a rose 
color. In disease, they present important alterations in respect to 
their position, motions, volume, color, state of dryness or humidity, 
and the eruptions of which they are the seat. 

They are pendent in adynamic fevers, and in the agony of vari- 
ous diseases ; they are widely separated from each other in forward 
dislocation of the lower jaw ; compressed and contracted in violent 



SYMPTOMS. 89 

pain ; trembling, in some nervous affections : they are suddenly- 
thrust forward and separated at each expiration in certain cerebral 
affections ; this is said to resemble a person in the act of smoking a 
pipe. The lips are drawn to the right or left, when one side of 
the face is affected with paralysis, or convulsion ; in the latter 
case the symptom is called a cynic spasm (spasmus cynicus); * 
when the two commissures are drawn away from each other, it is 
called the risns sardonicus.-f It has been said that the upper lip 
is thick in scrofulous persons, but to this there are numerous ex- 
ceptions. Swelling of both lips precedes and accompanies the 
eruptions which sometimes appear at the decline of certain acute 
affections. 

Their color is of a vermilion red in inflammatory diseases, pale 
in anemia and chlorosis, livid in the cold stage of intermittent fevers 
and in organic lesions of the heart. 

The lips are dry, ordinarily smooth, sometimes cracked, in grave 
fevers ; they may also become covered with a dry and blackish 
coat, similar to that which appears upon the teeth and tongue. 
This dryness and these deposits of buccal mucus are sometimes 
observed in the lightest affections, and even in healthy persons who 
sleep with the mouth open. The necessity of sleeping with the 
mouth open is connected with an anatomical disposition which we 
do not recollect to have seen pointed out. It consists in a malfor- 
mation of the roof of the mouth, which being too much arched 
towards the nasal fossae and too narrow between the dental arches, 
produces, as the inevitable result, narrowness and shortness of 
the nasal fossae, or rather a drawing up of the upper lip. All 
those persons, in whom the upper lip does not cover the teeth, 
not extending below the alveoli, sleep necessarily with the mouth 
open. 

The chin participates in the changes which the face undergoes ; 
there are few which are peculiar to it. It deviates from the 
median line of the body in dislocation of one side of the jaw, and is 
often deformed in fracture of this bone. It sometimes becomes the 
seat of an herpetic eruption, known by the name mentagra. It 
presents in the agony, at the moment of the last inspiration, a con- 
vulsive falling which immediately precedes death. 

The parotid regions become, in some affections, the seat of a 
remarkable swelling, affecting the glands themselves or the cellu- 
lar substance in which they are enveloped. This swelling, which 
occurs in typhus and many other acute diseases, either at their 
commencement or termination, demands the careful attention of the 
physician. To this symptom the term parotis has been applied. 
It may be confined to both sides, or extend to both at once, or suc- 
cessively ; it may be hardly perceptible or very considerable, &c. 

* Kvtav, xvvoc, a dog. 

f It has been said that this name was given to the convulsive laugh, from its 
having been sometimes produced by the use of a plant [ranunculus] which grows 
in Sardinia, ab herba Sardonia. 

8* 



90 SYMPTOMS. 

The ears are livid and cold during the first stage of intermittent 
fevers ; red and burning in the paroxysm of nearly all febrile 
affections, and particularly those accompanied with a determination 
of blood to the head. The meatus externus may become the seat 
of various discharges, as mucus, pus, blood, and in some cases frag- 
ments of bone. In some affections, the air which penetrates into 
the cavity of the tympanum through the eustachian tube, may 
issue from the meatus with sufficient force to agitate a light placed 
before it, or to produce a gurgling sound as it mixes with the pus 
which may be contained in the part. This canal may be con- 
tracted, or obliterated by vegetations or polypi, tumefaction of its 
lining membrane, the accumulation and desiccation of the matters 
it secretes, pressure exerted upon it by an abscess formed in its 
substance, or tumor developed near it. The mastoid process may 
become unusually prominent in consequence of disease of the bone ; 
atrophy of this bone has been sometimes noticed, following caries. 

The loss of the hair, which Hippocrates supposed to be a symp- 
tom of phthisis, rarely accompanies this disease. It is of frequent 
occurrence in syphilitic affections, affecting the beard and other por- 
tions of the pilous system; the hair is after a certain time partially 
restored. Where this is not the case, the phenomenon is desig- 
nated by the term alopecia* a rare symptom, the causes of which 
are unknown. The fall of hair is not unfrequently noticed during 
convalescence from typhus and eruptive fevers. The hair turns 
white in some instances, under the influence of a severe moral 
shock. It becomes of a greenish hue in those who work in copper, 
and red in those employed in the preparation of minium. 

In tinea, the hair falls off, and is replaced by wooly tufts scat- 
tered over the scalp. In plica polonica, the inextricable interlacing 
of the hair is the principal symptom of this singular disease. 

The neck becomes increased in bulk in some anginose affections, 
and in goitre ; it is diminished in size, with other parts, in general 
emaciation, when it appears lengthened. The distension of the 
superficial veins of the neck and external jugulars, the undulatory 
reflux of the blood in these vessels, from the clavicle where it is 
very apparent, to the neighborhood of the jaw where it is no 
longer perceptible, has been pointed out as alone existing in aneu- 
rism of the right cavities of the heart ; but more accurate obser- 
vations have shown that it occurs as well in affections of the left 
as right side of the heart, and particularly in contraction of its 
orifices. Pulsations of the carotids are frequently observed in 
active aneurism of the left ventricle ; this symptom also sometimes 
precedes delirium in acute diseases. Enlargement of the lymphatic 
glands is one of the most important symptoms presented by the cer- 
vical region. It accompanies or precedes acute and chronic 
eruptions of the face and scalp. Sudden swelling of the glands, 
accompanied by febrile symptoms, is an almost certain sign of ap- 

* Almnrfc, a fox. This animal is said to be subject, in old age, to the loss of 
its hair. 



SYMPTOMS. 91 

proaching erysipelas of the face. That which comes on slowly is 
often owing to an affection of one of the neighboring teeth. 

The chest, which in the healthy man is of a size proportionate to 
his stature and strength, is narrow and flat in pulmonary phthisis, 
and prominent in pulmonary emphysema. In rachitis, it presents 
various and numerous malformations to which we can here but 
allude, as they belong rather to the history of that disease, than to 
general pathology. The integuments covering the chest become 
very thin in chronic diseases ; in the last stages of phthisis they 
form over the whole, or but a part of its extent, deep depressions 
between the ribs. In empyema, on the contrary, the intercostal 
spaces are often more prominent than the ribs themselves; this pe- 
culiar disposition is only perceptible where the integuments are very 
thin. There are certain cases in which one side of the chest is more 
voluminous than the other; this morbid disposition may depend on 
one of two opposite causes, either enlargement of one, or contraction 
of the other side; so that the disease is sometimes seated in the 
larger, and sometimes in the smaller side. Enlargement is owing 
to dilatation of the pulmonary vesicles, or an accumulation of fluid, 
and sometimes of air, in the cavity of the pleura. Contraction 
always follows effusion, and consequently enlargement of the same 
side of the chest: the lung which has been for a time compressed, 
regains its dimensions, if at all, very slowly, and its parietes in ac- 
commodating themselves to it, lose part of their fulness. A more 
circumscribed portion of the chest may present a fulness or partial 
depression : the former is sometimes observed, though often with 
difficulty, in pleuritic effusion confined to the base of one side of 
the chest, and more manifestly, in cases of arterial aneurism de- 
veloped under the sternum or ribs, in pericarditis with effusion, in 
hypertrophy of the heart and in some cases of pulmonary emphy- 
sema. But to avoid error, it should be recollected that, according 
to the researches of M. Woillez,* the right side of the chest is 
normally larger than the left, the difference varying from one half 
a centimetre to three centimetres [about one inch] ; that in left- 
handed persons there is often observed a prominence upon the left 
side anteriorly, which seems to depend upon increased thickness 
of the soft parts ; that there are also persons whose chests are nat- 
urally prominent on one side, while they are depressed upon the 
other. The disposition is the reverse, in such cases, upon the 
opposite side. Partial contraction is particularly observable beneath 
the clavicles, in certain forms of tubercular phthisis, and more 
rarely at the base of the thorax, after the absorption of pleuritic 
effusions confined to that region. 

The mammai furnish certain symptoms which will be consid- 
ered elsewhere. 

The shoulders are raised and prominent in phthisical patients; 
one is lower than the other in lateral curvature of the trunk, 
pointed out by Laennec in those suffering or convalescent from 

* Recherches sur Vinsp. et la mensur. de la poitrine. 8vo. Paris, 1838. 



92 SYMPTOMS. 

considerable and prolonged pleuritic effusion. Prominence of one 
of the dorsal vertebras is the most important symptom in Potts' 
disease. In spina bifida, a soft, fluctuating, and often translucent 
tumor in the vertebral region is distinguishable by the eye, and 
the absence of one or more spinous processes can be felt. A depres- 
sion at the lower extremity of the sternum, in some workmen, is 
rather owing to habitual pressure on the part by the instruments 
they employ, than to disease. This is most frequently observed in 
shoemakers. 

The exploration of the chest, by means of percussion and 
auscultation, reveals many other very important phenomena, which 
will be considered in the articles on the symptoms furnished by the 
respiration and circulation, and in the chapter on diagnosis. 

The abdomen, in health, varies in size in different individuals, 
and is moderately resonant; it is firm without hardness, and 
pliant without softness. 

The skin of the abdomen is generally smooth and of a white color. 
In women who have been once pregnant, and particularly those 
who have borne many children, whitish or bluish wrinkles are ob- 
served extending across the hypogastric region, to which the term 
vergetures has been applied, and which are certain indices of pre- 
vious pregnancy ; but it should be recollected that this sign fails in 
some women who have borne children, and sometimes occurs in 
persons of both sexes, in whom distension of the abdomen has 
previously taken place, either from a considerable accumulation of 
serum or fat. It is chiefly upon the surface of the abdomen that 
the rose-colored lenticular spots, peculiar to typhoid and typhus 
fevers, appear. The subcutaneous veins, in some cases of ascites, 
become considerably enlarged, forming a true varicose network, 
which will be hereafter considered {venous circulation). There 
often exists in pregnant women, on the median line, extending 
from the umbilicus to the pubis, a brownish coloration, owing to a 
superabundant secretion of pigmentum. The lower half of the 
linea alba sometimes presents below the umbilicus a very narrow 
opening, not easily distinguished, in which a small portion of the 
epiploon may become engaged. This affection has often given rise 
to obstinate vomiting and considerable emaciation, which has led 
to the belief in the existence of stomachal cancer, and which has 
been cured by the application of a bandage. It is therefore of the 
greatest importance in patients attacked with vomiting, to exam- 
ine with particular care the whole extent of the linea alba, as well 
as all other parts of the abdominal surface where hernia is liable 
to occur. Lastly, after repeated parturition, the linea alba some- 
times becomes thin and ruptured, allowing the intestines to form 
considerable tumors; and in subsequent pregnancies, the womb 
has been known to fall forward in front of the pubis, forming an 
enormous protuberance. 

The volume of the abdomen may be increased or diminished 
under the influence of disease ; its increase may be partial or 
general. In the latter case, it is almost always owing to the 



SYMPTOMS. 93 

presence of gas in the digestive canal, some fluid in the cavity 
of the peritoneum, or an abundant exhalation of fat within the 
cavity, and in the parietes of the abdomen. A moderate accumu- 
lation of air in the intestines increases the bulk and resonance of 
the abdomen : this is termed meteorism {meteor ismus).* If the 
accumulation be more abundant with distension of the abdomen, 
it is called tympanites ;\ these two words express nearly the same 
thing : the latter is, however, more generally employed in chronic 
diseases, and the former in acute affections, and particularly grave 
fevers. J 

The abdomen is frequently the seat of partial swellings. These 
occur in the hypochondriac regions in diseases of the liver and 
spleen, and in the epigastrium in hysteria. The bladder when 
distended with urine, forms an ovoid tumor in the hypogastrium, 
which sometimes extends to the umbilicus ; the intestines, stomach, 
uterus, ovaries, and mesentric glands, may also form, in the dif- 
ferent regions of the abdomen, tumors more or less distinct to 
the touch and sometimes to the eye : so with the cysts which are 
occasionally developed within this cavity, &c. These various tu- 
mors are, in some cases, very apparent, in others, they are alone 
evident from an obscure and deep seated resistance which they 
present. 

Diminution in the volume of the abdomen may be general or 
partial. 

Its A^olume is diminished in many chronic diseases, in conse- 
quence of the general emaciation. It becomes suddenly dimin- 
ished also in some acute affections, as in violent colic, and par- 
ticularly that produced by lead. In adynamic fevers and perito- 
nitis, the abdomen often falls away a short time before death : a 
similar phenomenon is sometimes observed in patients who die 
dropsical. The abdomen becomes alternately diminished and 
increased in size in some affections, and particularly in hysteria 
and schirrus of the large intestines. The most important sign of 
the latter affection is prolonged constipation with progressive 
enlargement of the abdomen, alternating with abundant stools, 
which are followed by immediate sinking of the abdominal pari- 
etes. In hysteria, on the contrary, enlargement of the abdomen 
comes on rapidly, in consequence of gaseous exhalation, often 
disappearing as rapidly, without the appearance of any evacua- 
tion. Partial diminution of the abdomen is more rarely observed 
than circumscribed swelling: it is relative rather than absolute, 
and commonly succeeds the latter : such is that observe'd in the 
epigastrium, in some nervous affections, in the hypogastrium after 
the excretion of urine which has been for a long time retained in 
the hypochondriac regions, on a favorable termination of engorge- 
ment of the liver or spleen, &c. A partial diminution may, how- 
ever, take place in some very rare cases ; as depression of the 

* MtTtwQifiuoi;, from utrtutQos, elevated, 
f Tvunavov, a drum. 
| Franck, t. vii., p. 55 . 



94 SYMPTOMS. 

epigastrium and left side from displacement of the spleen or 
stomach. Many examples of this are cited by Morgagni. M. 
Rayer has recently shown that displacement of a kidney may also 
give rise to these phenomena. In a case, in which the kidneys 
appeared placed transversely across the vertebral column, the lum- 
bar region was depressed and flattened like the two sides of a 
saddle.* It is necessary, in order to distinguish this appearance, 
that the patient be placed on all fours. 

The form of the abdomen is generally in relation to its 
volume; both increasing and diminishing simultaneously. The 
abdomen may, however, become very hard, although diminished 
in volume, as in metallic colic. An unusual resistance felt over 
the whole region is, in some cases, the only symptom of chronic 
peritonitis. The abdomen is soft in some cases of dropsy, when 
the quantity of fluid has been lessened by absorption or punc- 
ture. 

The form of the abdomen varies according to the disease that 
produces its increase ; in ascites, its dilatation takes place particu- 
larly from before backward, and the umbilicus, raised by the fluid 
that distends it, sometimes forms a small, pellucid tumor, which 
rests upon the enormous swelling presented by the abdomen. In 
cedematous swelling of the abdominal parietes, on the contrary, 
the transverse diameter is the greatest, and the flanks acquire an 
extraordinary width. In both cases the abdomen, to use the 
vulgar expression, falls to that side on which the patient lies ; its 
form, in other respects, is regular. It is otherwise in the cases in 
which the increased size is owing to an encysted tumor, or to an 
organic affection of any viscus : in such cases, unless there be 
accompanying ascites, the abdomen presents a remarkable irregu- 
larity of form, particularly in the first stage of the disease. 

The abdomen presents at various points, and particularly at the 
umbilicus, inguinal ring, crural arch, and on a level with the 
obturator foramina, tumors which appear and disappear, or at least 
become increased and diminished under certain circumstances, 
and which are formed of some one of the parts naturally contained 
within the cavity of the abdomen, protruding through one of 
the apertures alluded to. These tumors, which are called hernial, 
may occur in the thorax and head ; but they are as rare in those 
parts, as they are common in the abdomen. The inguinal regions 
are also the seat of many important phenomena, such as the 
buboes which occur in syphilis and the plague. The abscesses 
formed in the iliac regions and in front of the vertebral column, 
make their appearance in these regions. 

The organs of generation furnish several important phenom- 
ena : the primary symptoms of syphilis almost always occur in 
these parts, and it is here that discharges, ulcers, vegetations fre- 
quently manifest themselves. 

The penis is increased beyond its natural size in children af- 

* Rayer. Malad. des Reins. Obs. xxxiii., t. 1, p. 407. 



SYMPTOMS. 95 

fected with stone, in those addicted to masturbation, and in adults 
who have indulged immoderately in the pleasures of love. It is, 
in most diseases, in a state of permanent flaccidity ; it disappears 
beneath the integuments in some affections of the scrotum and 
tunica vaginalis. In other diseases, as blenorrhagia and satyriasis, 
it is, on the contrary, continually in a state of erection. The 
testicles are retracted strongly against the inguinal ring in cases of 
nephritic calculus, ilio-scrotal neuralgia, and violent colic; this 
retraction is, in some cases, attended with very severe local pain. 
The epidydimis and spermatic cord are the common seat of the 
inflammation which is said to be the consequence of repelled go- 
norrhoea, and which was for a long time supposed to be an affection 
of the testicle itself, which is but rarely and secondarily affected. 
The tunica vaginalis, distended with the fluid it exhales, is the 
ordinary seat of hydrocele which sometimes also affects the sper- 
matic cord. The scrotum is considerably swollen in anasarca, 
voluminous inguinal hernise, urinal abscesses, &c. 

The labia majora, in the female, often become enormously swol- 
len in dropsy ; they are sometimes, as are the testicles in the male, 
the seat of violent inflammation, succeeding and alternating with 
parotiditis. The vulva is the seat of ulcerations and vegetations 
of a syphilitic origin, and not unfrequently of lypomatous and 
steatomatous tumors. The labia majora may also, together with 
the clitoris, become hypertrophied ; the various malformations 
which characterize the female hermaphrodite and the tumors which 
take their rise in the uterus, here make their appearance. Lastly, 
there is sometimes observed, during pregnancy, a varicose develop- 
ment of veins, which is often but precursory to a much more 
serious disease, the trombus or sanguineous tumor, an affection 
which is peculiar to the period of labor. 

The limbs also furnish to symptomatology numerous phenomena. 

They are immovable and pliant in paralysis; their immobility 
is accompanied with stiffness, in softening of the brain, in various 
organic diseases of this viscus, in rheumatic affections, cramps and 
tonic convulsions ; their movements are disordered in some nervous 
affections, as chorea and hysteria. 

They become increased and diminished in size in those diseases 
which produce like effects in other parts of the body. 

One of the limbs may become cedematous and engorged, when 
the vessels and nerves which are distributed to it, are compressed 
by a tumor. A tumor in the side may produce these results in the 
corresponding thigh ; the arm is similarly affected in aneurism of 
the arch of the aorta. These phenomena principally depend upon 
some obstruction to the venous circulation, which may also produce 
a varicose development of the superficial veins. 

The limbs often become swollen around the articulations, or in 
the parts between; the first takes place in articular rheumatism, hy- 
darthrosis, white swelling, &c. ; the second, which is much more 
rare, sometimes occurs in scurvy, in which the muscles become the 
seat of a sanguineous exhalation between their fibres ; phlegmon, 



96 SYMPTOMS. 

abscesses and aneurisms may also produce partial swellings in 
these as in other parts of the body. 

The limbs become diminished in size, in paralysis; in such 
cases the paralyzed limbs are those affected, in paraplegia both 
thighs, in hemiplegia the leg and arm of one side. In the paralysis, 
which occurs in children, increase in the length of the limb is 
sometimes checked, the part remaining for several years shorter 
by some inches than the other, and smaller in other respects. 
This atrophy is often observed to follow spontaneous dislocations. 

The extremities of the limbs also present remarkable changes, 
in respect to size. Without noticing the diseases of which they 
are the special seat, as gout and caries, the hands are swollen in 
scarlatina and variola : it has also been remarked, that in plethora, 
the general intumescence is much more apparent in the hands 
than elsewhere ; the fingers are sometimes so much swollen as to 
be with difficulty flexed. Beclard having observed that, in many 
children affected with cardiac aneurism, the last phalanx of the 
fingers was so much enlarged as to give the finger the form of a 
small club, was led to believe that a connection existed between 
this peculiarity and lesions of the heart, and considered it a sign 
of those diseases. This form of the fingers has been more recently 
thought to be peculiar to tubercular disease of the lungs. This 
phenomenon does not appear to us, in a semeiotic point of view, 
to deserve the importance that has been attached to it. 

The feet become swollen in some affections, and particularly in 
incipient anasarca. 

The alterations in color presented by the skin, are, in some af- 
fections, more marked at the extremities than in other parts of the 
limbs and trunk ; as the lividity which occurs in the cold stage of 
febrile affections, the marbled appearance observed in some ady- 
namic fevers, and the bluish tint which occurs in Asiatic cholera, 
in diseases of the heart, and in all cases where there is any ob- 
struction to the pulmonary or cardiac circulation. We have seen 
the feet of a woman affected with elephantiasis, of a greyish slate 
color, with deep and regular furrows, and a hard and swollen con- 
dition of their tissue. 

The nails deserve little attention, in relation to symptomatology ; 
they are pale or livid in the cold stage of intermittent fevers, and 
present a yellowish tint in icterus. Hippocrates observed that 
they were curved in phthisical patients : this phenomenon, what- 
ever be its cause, is here rarely well marked. 

Such are the principal symptoms furnished by the exterior of 
the body ; there are many others which we have not considered, 
as their place is more naturally among those furnished by each 
particular function. 



SYMPTOMS. 97 

SECTION SECOND. 
Symptoms furnished by the Organs of Locomotion. 

The organs of locomotion consist of the bones with their appen- 
dages, and of the muscles. The bones which serve as the base 
and support of all the other parts, affording them strength and 
stability, are the passive, while the muscles constitute the active, 
organs of locomotion. 

I. The symptoms furnished by the bones are generally connect- 
ed with diseases which are confined to these organs. They may 
however become the seat of syphilitic tumors, scurvy may effect 
separation of the cartilages and apophyses, before complete bony 
union has taken place, and tubercular disease may produce en- 
largement and caries. 

The two principal symptoms of diseases of the osseous system, 
are deformity of the part and difficulty of motion. The former is 
present in nearly all fractures and dislocations ; it is also apparent 
in osteo sarcoma, and particularly in rachitis or softening of the 
bones. In the latter affection, the limbs are not only incapable of 
supporting the body in the upright position and of every kind of 
regular motion, but they may be bent by the hand into any form. 
Difficulty or complete loss of motion, accompanies nearly all the 
affections of these organs ; in some cases, voluntary motion is 
alone suspended, and the limb is capable of receiving the motion 
communicated to it, as in case of fracture ; in other cases, every 
kind of spontaneous or communicated motion is impossible, as in 
anchylosis and some dislocations. 

Another not less remarkable phenomenon is crepitation (crepita- 
tio), a name given to the peculia»sound occasioned by the friction 
between the fragments of a bone, either broken, or separated from 
its apophyses or the cartilages to which it is naturally united. 

A bone which has been laid bare by a wound or abscess, may 
present to the qye alterations in color and structure ; it sometimes 
becomes of a dull white color, or presents a blackish tint ; soften- 
ing of its tissue may occur, giving rise to a more or less abundant 
sanies, and causing it to break down readily under the pressure of 
a blunt instrument (caries). 

The slow decay of a bone, in a greater or less portion of its 
extent, gives rise to peculiar symptoms. This decay sometimes 
commences without any known cause, as in vertebral disease, in 
which it produces angular curvature of the spine. It is by trie 
wearing away of the sternum and ribs, that an aneurismal tumor 
becomes apparent through the thoracic parietes. The walls of the 
cranium are sometimes worn away by fungous tumors, and by 
gently depressing them, the bony circle which surrounds them 
may be felt. In the latter case, before the destruction of the bony 
tissue is yet quite complete, the thin lamina which remains, if 
compressed, emits a sound like that of parchment. 
9 



98 SYMPTOMS. 

II. The muscles present functional changes by far more numer- 
ous. Their action may be increased, diminished, destroyed or 
variously perverted. 

Increase of muscular strength has only been observed in a few 
nervous affections, and particularly in mania, in which patients 
have been known to break the bonds which confine them, and 
successfully resist many persons. 

In most diseases, the force of the contractions is diminished ; 
the step is unsteady, the upright position painful or impossible, the 
motions feeble and uncertain, and often immediately followed and 
even preceded by a feeling of lassitude : many patients are obliged 
to remain quiet, and some are unable to leave their beds. Among 
the latter, there are also those who are unable to retain the sitting 
posture, to feed themselves, turn themselves in bed, and even to 
move their arms : in extreme cases, the hand of the patient, hav- 
ing been raised and abandoned to itself, falls like an inert body, 
obedient to the laws of gravity. This diminution of muscular 
power occurs, in different degrees, in incomplete paralysis ; it may 
in this case be confined to certain parts, like the affection of which 
it is the symptom. There is a peculiar alteration in the muscular 
contractility, to which no special name has been given, but which 
we shall here notice. We refer to that so constantly observed in 
typhoid fever, and which, often occurring at the commencement of 
this affection, becomes one of the most important signs in its diag- 
nosis. This alteration consists in a kind of titubation or trembling, 
and uncertainty in the gait and motions generally, which has been 
justly compared to that occasioned by intoxication. 

The complete abolition of muscular contractility and voluntary 
motion, constitutes paralysis (paralysis') ; * a term applied to the 
loss of sensation as well as of motion, and to the simultaneous 
abolition of both these faculties. • Hence, in medical language, to 
avoid ambiguity, the terms paralysis of motion, paralysis of sen- 
sation, should be employed. Paralysis is general in comatose 
affections, syncope, asphyxia, &c. It has been more generally 
designated by the term resolution des membres \r«solntio membro- 
rumj. If it affect but one side of the body, it is called hemiplegia ;f 
if the lower half, paraplegia, or paraplexia ; % if the arm of one 
side and the leg of the opposite, it is called crossed paralysis, 
which is very rare. It is sometimes confined to one or both wrists, 
as is occasionally observed in metallic colic, and more rarely in 
typhus. Paralysis often affects certain muscles which are devoted 
to a particular kind of motion, as is sometimes observed in lead 
colic, in which the extensors are principally affected, the hands 
and wrists being constantly and powerfully flexed. In some 
cases, it appears to affect but a single muscular fasciculus : this 
has been suspected in those cases, in which the tongue loses the 

* TTixQaXvatc, from naQaXva>, I relax. 

^'HutnXijyia, i l fu/iXi t i.ta, from iltnavg, half, and nX^acrot, I strike. 

i ZIuQaaXt/iiu, from nXtjoaw, I strike ; /ia(>a t dim. particle. 



SYMPTOMS. 99 

power of articulating certain letters, but appears to retain all its 
other motions. In permanent ptosis, or falling of the upper eyelid 
(collapsus palpebral), the elevator muscle is alone paralyzed. 
The muscular contractility may be variously perverted. 

1. Tremor consists in a feeble and involuntary agitation, attrib- 
uted by most physiologists to alternate contraction and relaxation 
of the muscles, or alternate contraction of opposite muscles. This 
symptom, which may be general or partial, occurs in the cold 
stage of intermittent fever and some nervous affections ; it is often 
produced by the action of mercury and lead on the economy, and 
sometimes by the use of coffee and alcoholic liquors; it frequently 
occurs in old persons from the effects of age. 

2. Rigidity (rigiditas) should be considered as a perversion of 
muscular contractility. The actual muscular power is, in this 
case, always diminished, although any attempt at communicated 
motion is met with more than ordinary resistance, as will be found 
to be the case, in attempting to draw the arm of the patient out of 
bed. This rigidity is evident to the patient himself; he moves his 
limbs slowly and with effort. Rigidity, like paralysis, may extend 
to all the muscles, or be confined to one side of the body, one half 
of the face, or to a certain few muscles ; it is often connected with 
some disease of the brain, particularly softening of its substance. 

3. Cramp (crampus) is a sudden but permanent contraction of 
one or more muscles, accompanied by hardness of their tissue, 
numbness and inability to execute any movement of the part thus 
affected. The muscles forming the calf of the leg are particularly 
liable to this affection. Many persons in health suffer from it ; it 
is of frequent occurrence in women during the last months of 
pregnancy ; it sometimes accompanies hysteria and painters' colic, 
and is of almost constant occurrence in the different species of 
cholera. 

4. Subsultus tendinum is a twitching communicated to the ten- 
dons by the involuntary and instantaneous contraction of the 
muscular fibres. This symptom is more observable at the wrist 
than elsewhere, and may be felt by examining the pulse of the 
patient. It is common in acute diseases of an ataxic form. 

5. Carphologia* or carpologia, f consists in an automatic and 
continual agitation of the hands and fingers, which, in some cases, 
appear to seek flocculi in the air, and in others, to ramble about 
on the bedclothes. This symptom, which frequently accompanies 
very severe acute diseases, sometimes presents itself under a differ- 
ent form, the patient continually endeavoring to pick imaginary 
flocculi from the bedclothes : this is called crocidismus, % which 
many authors have confounded with carphologia. 

6. Convulsions {convulsiones) || consist in involuntary contrac- 
ons of the muscles. They are divided into clonic and tonic.$ 

* KaQcptj, flocculus ; *«yw, I collect. 

| KaQTzog, wrist, a part of the hand ; I collect with the hand. 

j 7<C(>oxi<Jitu>. This word signifies to pluck off the nap. 

From convellere, to shake. 
$ Some authors have sought to establish a distinction between convulsion and 



100 SYMPTOMS. 

A. Clonic convulsions (spasmi clonici) * consist in violent 
and involuntary contractions, which alternate with relaxation of 
the contracted muscles, or with contractions of other muscles. 
The effects of these convulsions in hysterical females are various. 
Some throw their limbs to the right and left, unconsciously strik- 
ing themselves, and rapidly flexing and extending their forearms 
and fingers. In others, particularly if the arms be confined, the 
body is alternately raised and depressed during the whole attack. 
We saw at the Hospital Saltpetriere, in one of the wards of M. 
Landre Beauvais, a young girl suffering from hysteria, who, in 
each attack, after the ordinary convulsive motions had passed off, 
suddenly and unconsciously rose, and holding the arms extended, 
rapidly turned herself about, until the supervention of another 
paroxysm. These were not of long duration. We recollect 
another case, that of a young girl at the Hotel Dieu, who, while 
the attack lasted, rolled about upon the floor of the ward. These 
clonic convulsions are not always general ; they are sometimes 
partial in different nervous diseases, and even in hysteria and 
epilepsy. Dr. Whytt observed a very curious example of partial 
spasm in a young girl aged eight years. The masseter and tem- 
poral muscles were alternately contracted and relaxed and at 
irregular intervals, so as to imitate the pulsations of the heart, 
with this difference, that the muscular contractions were more 
than one hundred and forty, while the cardiac pulsations were not 
above ninety, in the minute. A violent fright put an end to this 
affection, the cause of which was unknown, and which resisted 
every method of treatment. In connection with clonic convulsions, 
may be mentioned the involuntary shaking of the limbs, to which 
Gaubius applied the term palpitatio membrorum. 

B. In tonic convulsions (spasmi tonici,)-f the muscular contrac- 
tion is permanent, so that the affected part is in a state of absolute 
immobility, which no internal or external effort can overcome. 
The equal and permanent contraction of all the muscles is called 
tetanic. J If the anterior muscles of the body be more strongly con- 
tracted, causing flexion of the head on the chest, and curvature of 
the body forward, the phenomenon is called emprosthotonos ; || if, 
on the contrary, the body be bent backwards, so that the back of 
the head approximates to the spine, it is called opisthotonos. § 
Lastly, to that variety, in which the muscles of one side are more 
powerfully contracted than those of the opposite, producing lateral 

spasm. They have applied the term convulsion to those which we have called 
clonic, and the term spasm, to tonic convulsions. But as Castelli observes, the 
words spasm and convulsion have always been employed synonymously, and as 
we have elsewhere remarked, no change should be made in the acceptation of 
words sanctioned by custom. 

* Snuafiog, from onaw, I contract ; xao»os, agitation. 

f Tovot, tension. 

t Ttrovoio, I stretch. 
'EfinQoo6tv, forward ; tovos, tension. 
"Omo&tv, backward ; rovot, tension. 



SYMPTOMS. 101 

curvature of the body, the term pleurosthotonos is applied.* It 
sometimes happens that, in tonic convulsions, lateral and backward 
curvature of the body take place simultaneously, as we had occa- 
sion to remark in the case of a young man recorded in the Journal 
de Medecine. f Permanent or tonic convulsion is not always 
general, being sometimes confined to a particular part, to the ele- 
vator muscles of the jaw, for example, and to those which separate 
the lips. In these cases it is called lrismus.% Cynic spasm and the 
risus sardonicus, which have been already mentioned, are also 
tonic convulsions. || 

C. Can the muscular fibres which enter into the composition of 
the stomach, intestines, heart and urinary bladder, become the seat 
of convulsions, analogous to those observed in the voluntary mus- 
cles ? Among the numerous facts which may serve to throw light 
upon this question, the emission of urine, of fecal matters and of 
spermatic fluid, in epileptic attacks the vomiting which occurs in 
hysteria, and the impossibility of swallowing, in some varieties of 
tetanus, are phenomena which would incline us to the belief that 
this derangement of contractility may affect all the muscles, 
whether voluntary or involuntary. If in these cases convulsive 
action be admitted, should it be referred to the tonic or clonic con- 
vulsions? This question, which appears to us of little importance, 
we think entirely insoluble. 

7. There is another perversion, or anomaly^ of muscular con- 
tractility, which is observed in catalepsy (catalepsia) ; 11 in these 
cases, the patient retains, during the whole attack, the same posi- 
tion that he had assumed at the time of seizure, or remains in that 
in which he may be placed, however uncomfortable it may be. 
That this is not rigidity, is evident from the facility with which the 
limbs are moved ; and the need of relaxation felt by the muscles in 
a state of contraction in health is no longer experienced in cata- 
lepsy. This symptom generally shows itself in females suffering 
from hysteria. We have known it to occur every other day in an 
insane woman. There is a variety of catalepsy which we once 
had occasion to observe, in which the patient retained the same 
posture that he had at the time of the attack, but did not preserve 
that communicated to him ; the limbs yielded to an external force 

* nXevQoodcv, laterally ; rovo$, tension. 

f Tome xxix. 1814. 

j Tyiafiog, gnashing. 

|| A curious symptom is mentioned by Dr. Kellie, in the twelfth volume of the 
Edinburgh Medical and Surgical Journal, as occurring in infants during dentition. 
It consists in a spastic contraction of the flexor muscles of the thumbs of the 
upper, and of the toes in the lower extremity, the former being rigidly contracted 
and permanently bent downwards, and laid flat upon the palms of the hand, and 
the latter bent down to the plantar aspect of the foot. This affection lasted from 
a few days to three months. — Trans. 

fy A privative, ofiixkug, regular. 

*[f Karalafi(i<it>u), I seize. 

9* 



102 SYMPTOMS. 

which placed them in a new position, but resumed the first, as soon 
as the force was withdrawn. 

8. A very remarkable perversion of muscular contractility is ob- 
served in the disease called St. Vitus' Dance {Chorea Sancti Viti). 
If the patient seek repose, he experiences sudden twitchings in the 
affected limbs ; if he attempt to extend his hand to any object, it 
becomes affected by two kinds of motion, which tend to draw 
it in opposite directions ; the one voluntary, by which the patient 
endeavors to accomplish his purpose ; the other, involuntary and 
irresistible, which opposes his efforts ; so that it is only by a series 
of oblique and divergent lines, that he succeeds in reaching the 
object. The lower limbs may also be similarly affected, pro- 
ducing an irregular and unsteady gait ; whence the term dance or 
chorea which has been applied to this affection. 

9. There is still another anomaly of muscular contractility, 
not less remarkable ; it consists in being unable to execute any 
motion in a regular manner, unless with rapidity. Such is the case 
with those who are unable to walk, but who run without diffi- 
culty ; so it is, as Gaubius remarked, in those who stutter when 
speaking slowly, but in whom this peculiarity disappears if they 
articulate rapidly. 

10. We shall, finally, notice contracture [contr actura,] which 
consists in permanent and chronic rigidity of the flexor mus- 
cles. These organs, whose length and thickness diminish, at 
the same time becoming harder, form under the skin inflexible 
cords, which prevent the extension of the limbs. This phenome- 
non is generally owing to a lesion in some part of the nervous 
system. 

Such are the principal symptoms furnished by the active and 
passive organs of locomotion. They aid in completing what has 
been already said in regard to the exterior of the body. 



SECTION THIRD. 
Symptoms furnished by the Voice and Speech. 

The voice, in health, is loud and sonorous ; it aids, by its inflec- 
tions, in expressing the various feelings, which man is capable of 
experiencing. The speech, or articulated voice, is ordinarily free 
and distinct. 

I. The voice rarely becomes stronger under the influence of dis- 
ease ; this, however, is sometimes the case in delirium. In most 
affections, and particularly those of the vocal and respiratory or- 
gans, it becomes more feeble. It may be entirely lost, constituting 
aphonia* This symptom should not be confounded with mussi- 
tation {mussitatio), in which the tongue and lips move as in the 
act of speaking, without producing any sound ; these two affec- 

• A privative, <p*»*n> voice. 



SYMPTOMS. 103 

tions are observed in some acute diseases ; they are also of frequent 
occurrence in the neuroses, and particularly in hysteria. Aphonia 
frequently occurs in the last stage of croup ; it may also depend on 
disease of the brain, spinal marrow or recurrent nerves. When it 
becomes chronic, it is generally owing to destruction of the vocal 
cords by ulceration, which is almost always of a syphilitic or tu- 
bercular nature, and in the latter case often co-existing with 
phthisis pulmonalis, as is shown by the researches of Louis. We 
should always be led to suspect the existence of this disease when 
aphonia has persisted for several months, and even when but of a 
few weeks' duration ; it is, in some circumstances, the first sign 
that reveals it. 

The voice may become modified in tone as well as strength ; it 
is preternaturally clear in some malignant fevers, and before, or 
during delirium ; it is shrill in certain forms of angina, whistling 
in tetanus, hoarse in hydrophobia and in pulmonary or laryngeal 
phthisis, nasal in different affections of the pituitary membrane, 
and discordant in certain diseases of the larynx, as was observed 
by Portal in the case of a woman whose voice, while speaking, 
became alternately shrill and hoarse. In some varieties of melan- 
choly, the voice, like the attitude of the patient, is in imitation of 
that of certain animals, as the dog and wolf; these varieties of mel- 
ancholy have consequently received the names cynanthropia * and 
lycanthropia. f Lastly, it has been observed that deafness effects 
a change in the voice, which, being no longer regulated by the ear, 
becomes altered in its tone and inflections. 

II. The speech presents certain alterations, which may accom- 
pany those of the voice, or be manifested alone. 

1. In certain grave fevers, the words are pronounced in a hesi- 
tating and trembling voice (vox tremula). 

2. Stammering (balbuties) is a defect of speech which prevents 
the free articulation of certain letters or syllables which, after an 
effort to pronounce them, are quickly repeated; this occurs in 
some diseases of the brain and in grave fevers. It is. as is well 
known, natural to some persons, and undoubtedly connected with 
some defect of organization. 

3. Articulation is slow in many diseases ; prompt in others. In 
others there is great fluency of speech. The latter symptom was 
observed by Senac several times at the commencement of the 
paroxysms in intermittent fevers. 

4. Portal had under his care a woman who commenced speak- 
ing with difficulty, but was unable to keep silent after uttering 
the first words : she was compelled to express by words all the 
thoughts that occurred to her, even when at church. This was 
the same patient in whom the discordance of sounds, which we 
have just mentioned, was noticed. There is a similar case, at 
present, in Paris. 

* JTi/wv, xwos , dog ; av&Qumog , man. 
^ .iu'xo?, wolf; av6gtu7io<;, man. 



104 SYMPTOMS. 

5. Loss of speech may exist independently of that of the voice, 
as is observed in dumbness, which consists in an inability to 
produce articulate sounds. The loss of the voice, on the contrary, 
is always accompanied by that of speech. The latter has been 
observed previous to apoplexy and in nervous diseases. It is 
sometimes the effect of poisoning. Sauvages relates that the 
robbers in the vicinity of Montpellier, caused their victims to 
drink wine in which had been infused the seeds of the thorn 
apple ; this narcotic, according to that physician, produces a 
transient dumbness, which gave the robbers sufficient time to 
escape. 

The peculiar method of exploration, to which Laennec has 
given the name auscultation* applied to the voice, led that phy- 
sician to the discovery of still other interesting phenomena, which, 
render the diagnosis of many frequent and grave diseases much 
more complete. These symptoms will be considered in connection 
with those which belong to respiration ; we have thought it better 
to consider all the phenomena furnished by the auscultation of the 
respiratory passages in the same article. 



SECTION FOURTH. 

Derangements of Sensibility and of Sensation, considered as Symptoms. 

The faculty of feeling is, in the natural state, imparted, vari- 
ously modified, to many organs; it may, as is well known, 
become developed, under the influence of disease, in all the others, 
with the exception of the epidermis and its productions. It is by 
virtue of this faculty that different impressions are transmitted to 
the sensorium commune ; some, called internal sensations, inform 
us of certain phenomena which are taking place within our 
bodies; others, to which the term sensations has been particularly 
applied, acquaint us with certain conditions or qualities of exter- 
nal objects about us. The faculty of feeling, considered generally, 
and the sensations, both internal and external, present under the 
influence of disease, numerous changes which we shall proceed 
to examine. 

I. The derangements of sensibility which occur in disease, 
have been, by many physicians, considered as the effect of an 
unequal distribution of this faculty. Excessive pain in any part, 
they suppose to be the result of a morbid accumulation of sensi- 
bility, which in some subjects constantly takes place in some par- 
ticular organ, and in others, successively in different parts. This 
theory does not appear to us to accord with facts. If there 
be some individuals in whom the sensibility, when augmented in 
any part, becomes diminished in all others, this is by no means 

* From auscultare, to listen. 



SYMPTOMS. 105 

the case in the greatest number. It generally happens, as has 
been observed in hypochondria and hysteria, that the sensibility 
is diminished or increased in all the organs at once : it is equally 
augmented in all parts during the first period of certain acute 
cerebral affections ; it becomes everywhere simultaneously dimin- 
ished, and even extinct, in the second and third periods of these 
affections. 

Loss of sensibility is often connected with that of muscular 
contractility, particularly in cases where there is also loss of con- 
sciousness : the same cause, as compression of one of the cerebral 
hemispheres, may produce both these effects. There is then pa- 
ralysis of motion and of sensation. In many cases of cerebral com- 
pression, in which there is a diminution or entire suspension of 
motion, the faculty of it is preserved, as also in some rare affec- 
tions, whose material cause is unknown, the muscles preserve 
their contractility, while the integument that covers them is 
deprived of feeling. Some very ingenious researches have been 
recently undertaken, with a view to throw light upon this point 
in pathology : these led to the supposition that the exclusive office 
of the anterior and posterior fasciculi of which the medulla 
oblongata and spinalis are composed, is to transmit, the one 
motion and the other sensation, so that lesions confined to either 
one or the other, or to the parts from which they take their origin, 
produce derangement alone of one or the other of these func- 
tions, while those which affect both these nerves, or the whole 
spinal cord, would produce simultaneous derangement of motion 
and sensation. In support of this opinion, may be mentioned 
certain cases communicated to the Academy of Medicine, or pub- 
lished in the periodical collections ; but these facts, which have 
been contradicted by other experimenters, are yet too limited in 
number, and require further confirmation. 

II. The internal sensations, in the healthy individual, chiefly 
consist in the wants connected with the regular exercise of the 
functions ; in disease, these wants, together with the functions on 
which they depend, become deranged ; other sensations also man- 
ifest themselves, which belong exclusively to disease, and which 
demand the attention of the physician ; such are the various kinds 
of pain. 

As the nature of pain is familiar to all from experience, it will 
be useless to attempt its definition. 

Pain maybe produced by various causes with which we are but 
partially acquainted ; its effects may be less difficult to appre- 
ciate ; it varies in its nature, intensity, type, and seat. 

The causes productive of pain in diseases are : 1, considerable 
alterations in the tissue of parts which are its seat, as wounds, 
inflammations, ulcerations, and organic affections; 2, a too vio- 
lent or long sustained action ; 3, an inexplicable modification in 
the motion of organs which become primarily or sympathetically 
painful, without any manifest cause. 

The effects of pain are generally more apparent: 1, it de- 



106 SYMPTOMS. 

ranges the functions of the suffering organ ; in the muscle, it ob- 
structs or hinders the motions, in the mouth, affecting mastica- 
tion, in the thorax, respiration; 2, it also determines, in some 
cases, an afflux of fluids, either to the surface or tissue of organs ; 

3, it may produce sympathetic disturbance in distant parts, as 
vomiting in headache, and convulsions in many kinds of pain ; 

4, it may cause, when occurring in its highest degree of intensity, 
disorder of nearly all the functions, and when prolonged may 
result in death. 

Pain may exist variously modified ; each of its principal vari- 
eties has received particular names : 1, that which consists in a 
feeling of distension, has been called tensive ; it occurs especially 
in phlegmonous inflammation; 2, a heavy pain is a feeling of 
weight which accompanies collections of fluid in natural or acci- 
dental cavities, and which is sometimes felt in many other affec- 
tions ; 3, a throbbing pain is marked by its pulsations which are 
isochronous with those of the heart ; it is felt particularly in 
inflammatory tumors, in which suppuration is about to take place ; 
4. lancinating pain is characterized by transient lancinations or 
shootings which do not correspond to the arterial pulsations ; this 
kind of pain is peculiar to cancer and neuralgia ; 5, a boring pain 
has been admitted, because those who experience it, compare it to 
the sensation which a wimble or screw would produce in entering 
and turning on itself in the suffering part; it is felt in some cases 
of rheumatism ; 6, a contusive pain resembles that produced by a 
bruise : it frequently occurs among the precursory phenomena of 
acute diseases ; 7, the pain which is felt in anthrax and in gan- 
grenous erysipelas, is compared by patients to that produced by 
the contact of ignited bodies ; this has been termed burning pain ; 

8, the prurigenous pain, or itching, occurs in diseases of the skin ; 

9, there is another kind of pain, which is called formication 
(formicatio), from its resemblance to the sensation which would 
be caused by a multitude of ants creeping over the part. Finally, 
pain may be tearing or pungent. Some patients compare their 
sensations to a wound whose edges have been removed, or the 
surface of which has been irritated by some mechanical agent ; 
others, to compression of the part by an iron band, or the fall of a 
heavy weight upon it, &c. Pain may become changed in char- 
acter in the course of a disease : thus, in the first stage of phleg- 
mon it is tensive, in the second, throbbing, and heavy, when sup- 
puration has taken place. 

Pain varies in its degree of intensity : this may be determined 
by the report of the patient, his expression of countenance, ana 
the functional derangement it occasions. It may depend upon the 
cause which produced it, or the sensibility of the individual and 
particularly of the suffering organ. It is increased and diminished 
under different circumstances ; it is sometimes aggravated by heat, 
at others, by cold; in the one case it is excited, in the other, mod- 
erated by external pressure ; prolonged movement in the former 
case, increases, in the latter, diminishes it. The expression of the 



SYMPTOMS. 107 

physiognomy, under the influence of pain, varies with the constitu- 
tion and character of the patient. 

The type of pain is sometimes continuous, with or without 
exacerbation, sometimes intermittent, with or without regularity. 
In the first case, the pain is uninterrupted, and of different or 
equal intensity ; in the second, it ceases and reappears at regular 
or irregular intervals. Every pain which is reproduced without 
one of the types peculiar to intermittent fever, and the duration of 
which, at each return, is about the same as that of a paroxysm, 
deserves particular attention, as it is generally due to the same 
causes which produce intermittent fevers, and will yield to the 
same treatment. 

There are certain pains, which are felt simultaneously in all 
parts of the body, as those which precede and accompany the 
invasion of some acute diseases ; but they are generally partial, 
and even confined to a limited portion of the body. In some cases, 
they remain seated in the same place, in which case they are 
termed fixed; in others, they change their seat once or more; 
these being called vague or movable. * Fixed pains should 
always arouse the attention of the physician, for they are often 
indicative of important visceral changes. Thus, a circumscribed 
and continuous pain in the head, occurring in old persons, often 
proceeds from cerebral softening, in its incipient stages. 

There are certain other painful sensations, which, though not 
exactly corresponding to pain, closely resembles it : such are the 
general uneasiness and inquietude which accompany different dis- 
eases ; such also is anxiety which consists in extreme uneasiness, 
often more uncomfortable and insupportable than acute pain, and 
which, though generally felt throughout the whole body, is partic- 
ularly referred to the epigastric region, obliging the patient contin- 
ually to change his position. The highest degree of anxiety is 
anguish, which is ordinarily attended by palpitations, dyspnoea, 
and a change in the expression of the features and plaintive res- 
piration ; such are also those internal movements attributed by 
patients to the displacement of some viscus, to some foreign body, 
and often to a ball or globe {globus hystericus), which, rising from 
the hypogastric region or the left side, seems to ascend to the 
pharynx, producing a sense of suffocation. 

* Pain has received different names, according to the portion of the body which is 
its seat. Cephalalgia (y.«paX>i, head, uXyog, pain) signifies pain in the head ; her- 
tnicrania (('mkfv;, half, xoanov, head) by corruption migraine, that confined to one 
of its sides, &c ; to cephalalgia is applied the epithet frontal, supraorbilar, synci- 
pital occipital, when it is exclusively confined to either of these regions. Pain in 
the ear is called otalgia ( to?, o>toc, ear) ; that of the teeth odontalgia (oiov$, oSor- 
toc, tooth). By the term point de coti, {stitch in the side) is understood a pain 
occupying the lateral part of the chest. Pain situated in the epigastric region 
has received various appellations, as cardialgia {y.anSta, orifice of the stomach), 
cardiogmus (zapcfiwyuo?, pain of the cardia), epigastralgia (tm, upon, yu.ni in, 
belly). Pain in the intestines is known by the name colic (xwXov, colon). Those 
of the kidneys, liver, and spine, have been termed by some authors, nephralgia 
(rtcpQos, kidney), hepatalgia (^too, liver,) rachialgia ((>o/ic, spine). _ Pain seated 
in the nerves is called neuralgia (vtvoov, nerve), and that felt in the bones 
osteocopus (ooxtov, bone, Xonxm, 1 break.) 



108 SYMPTOMS. 

To this same series of symptoms, might be added the sensation 
of cold or heat, which some persons experience in the whole or a 
part of the body ; but the consideration of the changes in animal 
heat, more naturally belongs elsewhere. 

III. External scnsatio?is. In health, the organs of sense receive 
the impression of external objects, and transmit it, with prompt- 
ness and precision, to the brain ; under the influence of disease, 
these impressions may become wearisome, the perception confused, 
irregular or defective. Derangement of the sensations is some- 
times produced by an affection of the organ which is its seat, and 
sometimes by the connection or association which may exist 
between that organ and the suffering part. 

The sight, hearing, taste and touch, may suffer the same de- 
rangements as other functions, as exaltation, diminution, abolition, 
and the various perversions, among which authors have classed 
hallucinations, and illusions of the senses. But, as Esquirol * has 
justly remarked, in hallucinations, the mind is the sole seat of the 
affection ; those, thus affected, indulge in day-dreams, their dis- 
ordered brains giving a body and reality to images reproduced by 
the memory, or created by the imagination, Avithout the interven- 
tion of the senses. In illusions, on the contrary, the patient is 
deceived in regard to the nature and cause of his real sensations. 
Illusions are not uncommon, even when the nervous system and 
organs of sense are free from disorder ; but they are perceived by 
the reason, and by it the patient is enabled to guard against them. 
The case is different with the sick, and particularly the insane 
man, whose reason is often at fault, and whose sensations are con- 
sequently received as real, and as conveying no false impression. 

A. Exaltation of vision occurs in ophthalmia, in inflammation 
of the retina, and of the meninges ; dimness of vision takes place 
in typhus, &c. ; its entire abolition, in blindness, amaurosis, cata- 
ract and certain nervous affections. The sight is sometimes singu- 
larly perverted : 1. It may exhibit objects which have no real 
existence, as sparks of fire, flashes, floating specks or spots resem- 
bling flies, cobwebs, light shadows, &c., (inetamorphopsia). 
2. It may change the color, form, and number of objects presented 
to the eye : thus in plethora and internal ophthalmia, objects some- 
times appear of a red color ; and during the first few days of 
jaundice, they are said to be colored yellow ; in certain neuroses, 
in some forms of amaurosis, and in incipient cataract, only one 
half or a portion of the object is visible: this is called hemiopsia* 
(visits dimidialus) • in other cases they appear double : this is 
diplopia f or double vision {visits duplicatus), which is ordinarily 
only observed when the two eyes are open; in a very remarkable 
case related by Maurice Hoffman, however, it persisted when one 

* Esquirol, des Illusions chez les alienes, a paper read at the Acadamie des 
Sciences, 1832 

iHuiavg, half; oTTToi/ai, I see. 
j JmXoog, double ; "V- e y e » 



SYMPTOMS. 109 

eye was closed. * This affection rarely exists, without strabismus ; 
if the want of concordance of the optic axes be not at first appa- 
rent, it will become evident if the patient be directed to turn his 
eyes successively to the right and left, and upward and downward. 

B. The hearing becomes frequently acute in meningeal in- 
flammation, &c. ; obtuse in typhus and grave fevers; it is not 
entirely abolished except in diseases of the ear, as chronic otitis 
with caries, and perforation of the tympanum, lesions which not 
uncommonly occur after variola, typhoid fever, and in the latter 
stages of phthisis pulmonalis. The hearing may be perverted in 
two ways : in one case, the patient imagines he hears sounds, 
which have no existence, as beatings, tinnitus, the ringing of bells, 
the noise of the wind, the murmur of water, the music of some 
instrument, words and even speeches ; in the other, he does not 
properly appreciate the sounds which he really hears, they ap- 
pearing to him more acute or grave than they really are ; and he 
does not recognize the voice of his friends. 

C. The exaltation of smell has been observed in the neuroses 
and some other diseases. Bally relates that when suffering from 
yellow fever at St. Domingo, he distinguished, in the cold water 
which he drank, the odor of the flowers which grew upon the 
banks of the stream from whence it was drawn. Diminution of 
this sense is much more frequently observed, as in coryza, ozseua, 
and all the acute diseases in which the pituitary membrane be- 
comes deprived of its moisture. If this membrane be entirely dry, 
the sense of smell no longer exists. In some cases of ataxic 
fevers, and in the lighter forms of hysteria, the patient complains 
of smelling odors which in fact do not exist, or perceives in sub- 
stances a different smell from that which belongs to them. 

D. The taste is rarely exalted in disease ; this symptom has 
however been observed in the neuroses. It is diminished in nearly 
all acute affections, and often suspended in the last stage of grave 
fevers in which patients take without repugnance the same 
remedies which had before excited nausea from having merely 
swallowed them. This sense also presents other anomalies ; some 
patients perceive an acid, bitter, saltish, coppery, or putrid taste 
in all their food, whether liquid or solid ; to others, substances 
which are disgusting or insipid, have a delicious flavor, while food 
of a superior flavor is to them positively disagreeable. This 
symptom is particularly observable in hysteria. 

E. The touch, taken in its most limited acceptation, rarely 
furnishes many remarkable symptoms; it may be diminished or 
abolished; it is rarely depraved. Sarcone remarked, in the epi- 
demic of Naples, that, of all the senses, this was least affected. 

* Ephem. Natur. Curios., vol. ii., obs. 1. 
10 



110 



SYMPTOMS. 



Taken in a more general sense, this sense may be exalted in the 
whole or a part of the body, as in general nervous affections, and 
in local phlegmasia. It becomes more or less diminished, or 
completely abolished, in apoplexy, paralysis of sensation ; it may be 
perverted, the patient incorrectly appreciating real sensations, or 
experiencing those which are imaginary, as in the sensation of a 
drop of water falling upon some part of the body, a pin penetrat- 
ing the skin, or the crawling of some animal over the body ; but 
these last phenomena belong to hallucinations, as well as to illusions 
of the senses, and constitute one of the signs of a disordered 
intellect. 



SECTION FIFTH. 
Symptoms furnished by the Affective Functions. 

These functions, in health, present the greatest variety in differ- 
ent individuals. 

Disease almost always produces a degree of sadness or impa- 
tience, ennui or inquietude. All these effects may be produced 
simultaneously, or successively, but in most cases, the derange- 
ment of the affective functions is more manifest. They are some- 
times exalted, as is observed in hypochondriacs; patients thus 
affected are at once susceptible of the strongest attachment and the 
most profound hatred ; the least evidence of good will affects them 
to tears, and on the slightest occasion they will form the blackest 
suspicions. In others, the opposite is observed ; they appear indif- 
ferent to their own fate, and that of their nearest friends ; in some 
cases of typhoid fever and mania, the moral sensibility is almost 
entirely abolished. The character and affections may be perverted ; 
persons who in health are the most amiable, become peevish ; 
those most imperious and obstinate, docile ; the most resolute, 
pusillanimous ; and the timid, resigned and even courageous, 
under the influence of disease. This has not escaped the observa- 
tion of those unconnected with the profession, and it is a common 
remark, that those who in health are the most amiable, are the 
worst patients. Disorder of the moral affections is still more mani- 
fest in some individuals, who, during a part or the whole course 
of a disease, take an aversion to their nearest and most intimate 
friends. This symptom is not unfrequently observed in hypochon- 
driasis and mania. 



SYMPTOMS. HI 

SECTION SIXTH. 
Symptoms furnished by the Intellectual Functions. 

The intellectual functions relate principally to the attention, 
memory, imagination and judgment; these presenting, in health, 
infinite varieties, and, in disease, being susceptible of numerous 
alterations. In some cases, there is perversion of the judgment and 
imagination, while the attention and memory remain unaffected ■ 
in others, the memory is alone at fault ; but generally all these 
functions are simultaneously deranged. 

Exaltation of the intellectual powers is a prominent symptom in 
some patients, and particularly in melancholies; we are often 
struck with the clearness and surprising accuracy of the memory 
by which they are enabled to recollect events long since forgotten, 
the appropriateness and precision of their language, their rapidity 
and strength of judgment, and fertility of imagination, in short 
a degree of intelligence far surpassing that which they ordinarily 
possess when in health. Nor is it rare to observe an extraordinary 
development of the intellectual functions, connected with exalta- 
tion of the moral sensibility, in acute disease about to terminate 
fatally. The dying often speak with an eloquence which they 
were not before known to possess, and express sentiments which 
they did not appear susceptible of experiencing. 

The intellectual functions are more often enfeebled than exalted 
in disease. This diminution of the intellectual powers, occurs in 
most diseases, particularly those of an acute character. It is prin- 
cipally in typhus that this symptom is noticed ; it is difficult to fix 
the attention of the patient; he comprehends with difficulty the 
questions that are put to him, replying slowly, and having but a 
vague idea of what is going on around him, the place where he is 
or his relations to those about him ; his physiognomy is not iti 
harmony with surrounding circumstances ; his attention is not 
directed towards the object that excites it ; his features are without 
expression, and the body remains in one posture. 

There is an entire absence of the intellectual faculties in idiocy 
and those diseases, in which there is a suspension of all the func- 
tions of relation, as violent apoplexy, and epilepsy. 

Perversion of one or more of the intellectual or affective faculties 
constitutes delirium* 

This affection is more likely to occur during childhood and 
youth than at any other period of life, and in persons of great ner- 
vous susceptibility. There are some individuals, in whom a slight 
indisposition, or febrile attack, is accompanied with this affection. 
But this symptom does not generally occur, except in severe acute 
diseases, or in chronic affections when drawing towards a fatal 
close. 

* Delirium, de, from ; lira, ridge between two furrows. 



112 SYMPTOMS. 

Delirium does not alone occur in affections of the brain and its 
membranes ; it is more often observed, as a sympathetic phenome- 
non, in the thoracic and abdominal phlegmasia?, eruptive fevers, the 
various kinds of typhus, and in typhoid fever. It is with the brain 
as with the heart, these two viscera being associated with the 
affections of all others, and the disturbance of their functions being 
generally sympathetic. This subject will be again considered in 
the chapter on diagnosis. 

Delirium may present itself under various forms ; it generally 
appears in the relations of the patient with external objects, in his 
gestures, actions, and in the words by which he expresses his ideas 
of surrounding circumstances; but there is also an internal deliri- 
um, sometimes observed, which depends solely upon disorder of 
the cerebral functions, and is not excited by any external circum- 
stance ; it is characterized by muttering, carphologia, automatic 
gestures, conversations with absent persons, &c. 

There is a state of complete delirium in which the order of ideas 
and moral affections is entirely perverted, the patient being contin- 
ually in error on every subject ; this is observed in mania. In 
other cases the disease affects but a single idea. This is partic- 
ularly observable in monomania, (melancholy of Pinel,) the patient 
entertaining erroneous ideas, as to his rank, the place where he 
is, and the passage of time; and consequently speaking and acting 
in accordance with this error. In complete, as in partial delirium, 
there is sometimes a predominant idea, which almost always relates 
to the habitual occupation of the patient, as is particularly noticed 
in coachmen, errand boys, &c. It has been observed that in those 
cases which present a predominant idea, it is almost impossible to 
dispel it, or to excite others in its place. 

Delirium may be constant, or transient ; in the latter case it may 
recur at regular intervals. 

The two principal varieties of this affection, which have been 
particularly described by authors, are the mild or tranquil and 
furious delirium. 

Mild delirium (subdelirium) can, in some cases, only be distin- 
guished by a change in the gestures, actions, and language of the 
patient; he tosses his arms to and fro without any determinate 
object ; tries to get out of bed, or uncover himself; he at one time, 
preserves an obstinate silence (tacit urnetas,) and at another, talks 
incoherently {vaniloquuirn) or mutters unintelligibly between his 
teeth. We have seen a case in which delirium could only be dis- 
tinguished by the plaintive cries constantly uttered by the patient. 
To most questions which were put to him, he replied promptly ; 
but when asked why he thus complained, he appeared unable to 
comprehend the question. Mild delirium may also show itself, by 
a more or less marked alteration in the physiognomy, sound of the 
voice, and in the mild, or severe, free, or respectful mode of ex- 
pressing himself, being not in accordance with the usual manner 
of the patient. It is not uncommon for them to speak harshly to 
those whom they have generally treated with respect, and vice 



SYMPTOMS. 113 

versa, having no recollection of the circumstance after recovery. 
In the case of a young man sick with typhus fever, who was under 
our care, the patient nearly recovered his senses about the twelfth 
day, the only evidence of any remaining delirium being the famil- 
iar tone with which he addressed an old friend of his family for 
whom he had always shown proper respect. Tranquil delirium 
should not be confounded with those distressing dreams which 
occur during sleep, and which cease upon arousing the patient. 

Furious delirium presents itself under a totally different form ; 
the patient shouting, singing and uttering threats ; talking in the 
most obscene and extravagant manner, railing against absent per- 
sons, quarreling and trying to leave his bed, throwing from him any 
object he can lay hold of, spitting upon, and striking his assistants, 
&c. The same patient may be alternately affected with mild and 
furious delirium. In the epidemic of Naples, according to Sarcone, 
furious delirium ceased during the remission; but the patients 
abandoned themselves to the most frightful despair, turning their 
eyes with a suspicious air upon their assistants, fearing to read in 
their countenances the unhappy fate with which they believed 
themselves threatened ; the least sign of affection caused them to 
weep and tremble with fright. 

Delirium presents other varieties, according to the difficulty of 
its cure. If it be light, it is perceived by the patients themselves, 
who endeavor to correct their own judgment. If the delirium be 
still more apparent, they may still have a desire to overcome it, 
but the difficulty is greater ; at this time the physician may cor- 
rect, at least for the moment, the ideas of the patient, and obtain 
sensible answers; but the amendment is but transient, and the 
delirium soon returns. When it exists in a still higher degree, 
nothing can suspend it, even momentarily. 

The duration of delirium is very variable. It may last for a few 
minutes only, or continue for weeks, months, and even years. 

After recovery from this affection, patients are often unable to 
recall anything that has occurred, not even what appeared to have 
been the result of reflection ; in other cases, they have a confused 
and even clear recollection of what they have experienced. 



SECTION SEVENTH. 
Symptoms furnished by Sleep. 

The usual duration of healthy sleep, is nearly uniform in each 
individual ; it is tranquil, and refreshes the wearied body. In dis- 
ease, it may be prolonged, diminished, suspended or disturbed, 
and fails to restore strength. 

It is prolonged in certain diseases accompanied by cerebral con- 
gestion, and diminished in nearly all acute affections. The com- 
10* 



114 

plete suspension of sleep or agrypnia * {insomnia, pervigilium) 
may occur in a great number of diseases, and from various causes, 
such as intense pain, tinnitus aurium and other imaginary sounds, 
difficulty of respiration, frequency of cough and of the excretions, 
restlessness, mental agitation, violent passions and nocturnal par- 
oxysms. Complete sleeplessness is one of the principal symptoms 
in '•'■delirium tremens ;" it is also a marked symptom in typhoid 
fever ; for, in no other acute disease, is it so complete and constant. 
Sleep may be disturbed by night-mare, dreams, &c. 

Nightmare (incubus),^ ephialtes% oneirodynia, § consists in a 
feeling of suffocation, which supervenes during sleep, producing a 
momentary but inexpressible anguish, and causing the patient to 
start and awake in terror. The person, who experiences this 
symptom, feels a sensation of great weight on his chest, imagines 
that some danger threatens him, or that he is pursued by a phan- 
tom ; he makes ineffectual efforts to escape from his imaginary 
dangers and to cry for help, and when he awakes is often bathed 
in perspiration. This symptom is particularly noticed in hypo- 
chondriasis and in cardiac aneurism, and may sometimes arise 
from indigestion. 

Most of the physicians of antiquity paid great attention to 
dreams ; they supposed that during sleep, that is, when the opera- 
tions of the mind are undisturbed by any external sensation, the 
suffering of the diseased organ is more distinctly felt, producing in 
the sensorium commune a disposition to certain dreams. This 
opinion is true, to a certain extent. In diseases accompanied with 
great difficulty of respiration, the patient imagines that the dilata- 
tion of the chest is prevented by the pressure of a considerable 
weight upon it. Galen mentions a man who dreamed for a long 
time, that one of his legs had become petrified ; a short time after, 
the limb became paralytic : the transient numbness which often 
precedes paralysis, sufficiently explains this phenomenon. It was 
more justly thought that ill nourished persons dreamed of eating 
certain articles of food. It has been pretended that in plethora 
and inflammatory fevers, patients perceive in their dreams, bodies 
of a red color ; that those suffering from dropsy, dream of water, 
streams, &c. ; but these assertions do not accord with observation. 

In general, when occurring in disease, dreams are wearisome and 
painful. They may present to the imagination, obstacles, precipices, 
fires, in short, any object of embarrassment and terror, sometimes 
causing the patient to awake suddenly in a state of fright. 

It is said that the Egyptians and Greeks placed their sick in the 
temples, that the gods might make known to them, in their dreams, 
the proper method of their cure. Now that the age of superstition 
has passed away, no one believes these salutary dreams to be the 
inspiration of heaven ; but respectable persons do not hesitate to 

* * Ayqa, chase ; vttvo?, sleep. 
| Incubus, from incumbere. 
j 'EifiaXiti;, from upaXXofiat. 

§ OttiQog, dream ; ofovi;, pain. 



SYMPTOMS. 115 

accord to the disciples of Mcsmer, the power of giving, with the 

magical sleep produced by their manipulations, the knowledge of 

every disease and its appropriate remedies. 

Lastly, the sleep of invalids does not restore the vigor of the 

frame ; and in some affections, the paroxysms of which occur in 

the night, the symptoms are of a more aggravated nature in the 

morning after a disturbed slumber, than towards the close of the 

day, after twelve or fifteen hours of wakefulness. 

Somnolency or drowsiness {somnolentia) is a state intermediate 

between waking and sleeping. It is often observed in typhoid 

fevers and in certain cerebral affections. 

Topor or cataphora * is a dull and heavy sleep, from which the 

patient can with difficulty be roused : this phenomenon occurs in 

the same diseases as somnolency. 

Coma f is a still more profound sleep, from which it is more 

difficult to awaken the patient. Of this there are two varieties : 
1. The coma vigil {coma agrypnodes), which is accompanied by 
delirium, the patient keeping his eyes closed, excepting when 
spoken to, muttering to himself, and frequently changing his posi- 
tion ; 2. coma somnolentum, in which the patient speaks when 
aroused, but remains silent and immovable in the intervals. 
These two varieties are frequently observed in typhoid fevers. 

Lethargy % {lethargus, veternvs) is a constant and still more 
profound sleep, from which however it is not impossible to awaken 
the patient ; but when roused from this state he forgets everything 
he has said, and appears unconscious of what he is saying, 
speedily relapsing into his former condition. 

Lastly, carus || consists in complete insensibility, from which 
nothing can arouse the patient, even for a few instants : these 
different symptoms most generally occur in the last stage of 
cerebral diseases, or in cases of concussion or sudden compression 
of the brain. 

Topor, coma, lethargy and carus, are somewhat analogous to 
sleep, only differing as it were in degree. It is for this reason, that 
they have been considered in connection with somnolency. 



SECTION EIGHTH. 

There are three other symptoms in which the functions of rela- 
tion are particularly affected, and to which we ought, perhaps, to 
allude before passing to the consideration of the disturbances of 
the internal functions ; these are lipothymia, syncope, and vertigo. 

Lipothymia || or lipopsychia, If consists in an almost entire sus- 

* KaTtxtpoQu, fall; xcncHpsQouai , I fall. 
| Konia, profound sleep. 
\Jrfit], oblivion ; oqy ?, idleness. 
|j Kunoc;, profound sleep, 
ty At i/r oi, I leave ; 6vfios, mind. 
^[ Atinw, idem ; t Ui( 1> soul- 



116 SYMPTOMS. 

pension of all the functions, with discoloration of the face and 
relaxation of the limbs. Respiration and the circulation continue, 
but are hardly perceptible. This symptom, when slight, is called 
fainting (animi deliquium). 

Syncope * presents the same phenomena, together with a more 
complete suspension of the respiration and circulation. Syncope, 
lipothymia and fainting may occur in consequence of acute pain, 
or lively emotions, copious bloodletting or abundant and painful 
stools. The ingress of air into the circulatory system, during a 
surgical operation, may occasion fatal syncope. This symptom is 
not unfrequently observed at the commencement of eruptive fevers, 
in the course of pestilential fevers, in gangrenous affections and 
cases of profuse suppuration. The periodical return of this affec- 
tion constitutes one of the severest forms of malignant intermittent 
fever. It is not uncommon at an advanced period of chronic 
diseases, and in persons very much reduced in strength, it often 
precedes sudden death. 

Vertigo {vertigines) produces in the patient a sensation of turn- 
ing, or gives to external objects the appearance of rotation around 
him ; this sensation is almost always accompanied by palpitation 
of the heart and a feeling of faintness. Vertigo tenebricosa f {capitis 
omnubilatio) is the term applied to that variety in which the sight 
becomes obscured as if by a cloud. This affection occurs at the 
commencement of many severe acute diseases, often returning 
during their course, particularly if the patient execute any move- 
ment, as in attempting to sit down or rise up. Vertigo, accompa- 
nied with a sudden loss of consciousness and soon followed by 
headache with a feeling of debility and heaviness, constitutes 
a form of epilepsy, apparently lighter, but more frequently 
followed by mental alienation, than the more common form of 
that disease. 



ARTICLE SECOND. 

Symptoms furnished by the Internal or Assimilative Functions. 

We have now considered the principal derangements presented, 
in disease, by the functions which serve to establish the relations 
of man with external objects. We shall next proceed to the 
examination of those furnished by the internal functions, diges- 
tion, respiration, the circulation, calorification and the secretions. 

* Zv/xotitw, I fall down. 
| Vertere, to turn. 



SYMPTOMS. 117 

SECTION FIRST. 
Symptoms furnished by Digestion. 

In health, the appetite returns at regular intervals, its gratifica- 
tion is attended with pleasure, the thirst is moderate, the stomachic 
digestion effected with freedom, without eructation or oppression, 
the faecal matters are of proper consistence, in quantity propor- 
tionate to the food, and their excretion is accomplished without 
pain. Each of the organs which contribute to the performance of 
this function presents a healthy appearance ; the teeth are white, 
smooth, and firmly implanted in their alveoli ; the gums are firm, 
smooth and of a pale red color ; the inner surface of the mouth is 
moist and of a reddish hue ; the abdomen, in which is contained 
most of the digestive apparatus, is of its natural size and sup- 
oleness. 

Under the influence of disease, every act of digestion, and all 
the organs which contribute to its performance, present more or 
less marked derangements, which we shall consider in the order of 
their succession. 

A. Hunger, the appetite or the desire of taking food is seldom 
increased in disease : this symptom is, however, sometimes ob- 
served in mania and verminous affections. In some cases, hunger 
is so urgent, that unless it is satisfied, fainting ensues ; this is 
called boulimus, * a phenomenon of common occurrence in hy- 
steria, but still more frequently observed during pregnancy. In 
other cases, the patient eats with voracity until the stomach 
relieves itself by vomiting; this is called {fames canwa)\. In 
other diseases, the food which is devoured with greediness, is 
almost as soon expelled by the anus ; this has been called (fames 
li/pina)t- The two latter symptoms are of rare occurrence. 

Diminution of appetite (dysorexia)§ accompanies nearly all the 
acute and chronic diseases of moderate intensity. 

In those of greater severity, and particularly in acute diseases 
attended with violent febrile symptoms, the appetite is entirely 
lost ; this is termed inappetentia or anorexia \\ . An entire and pro- 
longed absence of appetite, and progressive emaciation, are some- 
times the two only symptoms indicative, in adult age, of chronic 
disease of the stomach. 

In certain chronic diseases, the appetite is unequal to a remark- 
able degree ; the patient being one day affected with insatiable 
hunger, and the next, suffering from complete anorexia, this alter- 
nation sometimes occurring the same day. 

* 7?oxi, augmentative particle; Xifio?, hunger. 

t Canis, dog. 

$ From lupus, wolf. 

§ Jvc, with difficulty ; o(?*J<s, appetite. 

|| A privative, og£?«f, appetite. 



118 SYMPTOMS. 

In others, the desire of food is not real ; this is commonly called 
a false appetite. In these cases no sooner does the patient taste 
his food, than he feels already satiated ; this is particularly ob- 
served in phthisis. 

The appetite may become depraved in two ways. 1. There is 
disgust {cibi fastidium. apositia) * or aversion for food. Disgust 
should not be confounded with anorexia : the latter is only an entire 
absence of appetite, while the former consists in real repugnance for 
food. This repugnance is sometimes so great, that the sight of food, 
or the mention of its name, is alone sufficient to produce nausea. 
It is of rare occurrence except in grave diseases, while anorexia ac- 
companies the slightest disorder. 2. The other variety of depraved 
appetite, is that in which an almost general loathing is combined 
with a desire for some particular article of food ; if this substance 
be eatable, the symptom is called malacia f ; if, on the contrary, 
it be not eatable or noxious, it constitutes pica%. Both these 
symptoms frequently occur in hysteria and mania, and often in 
pregnancy. In connection with these affections of the appetite, 
may be mentioned the sensations of bitterness, clamminess, dryness 
of the mouth, experienced in many diseases, and particularly in 
febrile affections and gastric disorder. 

B. The thirst is increased in most acute diseases, and particu- 
larly in diabetes. It is rarely diminished, and more rarely abol- 
ished in patients whose intellectual faculties remain unimpaired. 
In the derangement of the ideas and sensations, accompanying 
delirium, the absence of thirst and refusal to drink exist together 
with other phenomena. 

C. The examination of the different parts of the mouth, fur- 
nishes us with important symptoms. We have before described 
the morbid appearances presented by the lips, and now proceed to 
consider those furnished by the teeth, gums, tongue, internal 
surface of the cheeks and back part of the mouth. 

The symptoms furnished by the teeth, may depend upon some 
affection of these organs themselves, or be connected with the 
existence of other diseases. 

In certain acute affections in which the secretion of the mucous 
membranes acquires a remarkable degree of acidity, the teeth 
become the seat of a peculiar sensation, in which they are said to 
be set on edge, (dentium hebetudo) ; this phenomenon is sometimes 
observed in continued fevers. 

The teeth of the lower, in gliding upon those of the upper jaw, 
produce a grinding sound {stridor dentium), a symptom which 
accompanies some acute cerebral affections ; in other cases, as in 
the cold stage of intermittent fever, there is what is termed chat- 

* ''Ana, oitiov, aversion for food, 
f MaXaxia, softness. 

j Pica or Kiaaa, magpie, its opposite colors form a contrast analogous to that 
afforded by the depraved, when compared with the natural, appetite. 



SYMPTOMS. 119 

tering of the teeth {dentrum collisus, crepitus), in which the teeth 
strike rapidly against each other. According to some authors* 
the force with which the teeth sometimes come together is sufi- 
cient to fracture them. In scorbutic affections, mercurial stom- 
atitis, and simple chronic engorgement of the gums, the teeth 
sometimes become loose and even entirely detached from their 
sockets. Lastly, in chronic diseases they appear elongated, owing 
to the shrinking of the gums which is coincident with the general 
emaciation. 

A thorough examination of the teeth is important, as many 
affections of the mouth are often produced and kept up by a 
decayed or falsely directed tooth. Among others, may be men- 
tioned caries and necrosis of the maxillary bones, odontalgia, 
fistula of the face, and enlargement of the lymphatic glands of the 
neck, which may be owing to no other cause than dental caries. 
Apthee, ulceration of the mucous membrane of the mouth, and 
particularly of the tongue, with hardened and inverted edges and 
a greyish and fungous surface, are not unfrequently caused by 
the inequalities of a broken or wrongly directed tooth. 

The gums present some important changes : they are swollen 
in mercurial salivation and scurvy ; in the former case, they are 
red, in the latter, blackish and flabby ; in both cases, they exhale 
an odor sui generis. It has been remarked by M. Rostan, at the 
Salpetriere, that after loss of the teeth, and when the gums had 
become callous from mastication, swelling did not take place in 
them to the same degree as before ; and if the teeth of one jaw be 
lost, while those of the opposite remain, the gums of the latter 
become swollen, while those of the former retain their usual 
appearance. * The gums become pale in diseases of debility, and 
particularly in passive dropsies ; they are of a redish brown color 
in some anginose affections. 

The state of the tongue, in disease, has always, and very justly, 
claimed the attention of physicians. The importance of the signs 
which it furnishes, has, it is true, been much exaggerated ; but if 
they be reduced to their true value, the tongue furnishes semiology 
with numerous interesting facts. 

In health, the tongue is generally of a red color ? smooth surface, 
slightly granulated towards its apex, and covered with pointed vil- 
losities and hemispherical glandules towards its base ; its surface is 
moist, it is free in its movements, the object of which is principally 
in speaking, mastication and deglutition. In chronic diseases, 
even in those of the stomach, the tongue often remains in its 
natural condition ; this is sometimes the case in acute diseases ; 
and this phenomenon which is without value in the first, is gen- 
erally a favorable sign in the latter case, provided the other 
symptoms be not unfavorable. Under the influence of disease the 
tongue presents changes in relation to its volume, form, movements, 

* De recondita Febr. int. turn, remit. ; Natura, p. 43. 
f Cours de Med. Clin., t. 1, p. 250. 



120 SYMPTOMS. 

color, moisture, coats, eruptions of which it is sometimes the seat, 
and lastly, its temperature and tactile and gustatory sensibility. 

The volume of the tongue becomes rarely increased in affections 
of which it is not the special seat. In some acute diseases, how- 
ever, this organ becomes so voluminous as to fill the whole month, 
preserving the impression of the teeth upon its surface. This 
phenomenon should lead the physician to suspect the influence of 
some mercurial preparation. At other times swelling of the tongue 
is in consequence of violent angina ; it is in these cases owing to 
stagnation of blood in this organ ; it is always a symptom indica- 
tive of great danger. 

Shrinking of the tongue is a frequent symptom in typhus and 
other grave, fevers ; it is at the same time in a state of dryness and 
tremor, conditions equally unfavorable. 

In marasmus, the tongue rarely becomes diminished in size. But 
a single example of partial atrophy of this organ has been recorded. 
This case, mentioned in the forty-fourth bulletin of the anatomical 
society, relates to a man, one half of whose tongue was pale, dis- 
colored, wrinkled and atrophied without any change in its sensi- 
bility. The patient died with symptoms of paralysis, and the 
autopsy revealed an hydatid cyst in the left occipital fossa which 
compressed the glosso pharyngeal nerve. 

The form of the tongue, in disease, presents remarkable varie- 
ties ; it becomes in some cases, conical, in others, pointed. The 
latter modification has been recently pointed out as peculiar to 
inflammation of the stomach, but this is not in accordance with 
the results of experience. These peculiarities in the form of the 
tongue do not indicate with certainty the nature and seat, more 
than the danger of the disease. The pointed form depends solely 
upon the mode of contraction of the intrinsic muscles of the organ. 

Difficulty in the motions of the tongue either in the articulation 
of sounds, or the act of protruding it, is a frequent symptom m the 
course of grave fevers ; this condition is always an unfavorable 
sign. 

In some cases of hemiplegia, when the tongue is thrust out of 
the mouth, its point appears drawn away from the paralyzed side ; 
it has been attempted to explain this phenomenon by supposing 
paralysis of the genio-glossus and stylo-glossus muscles. But this 
deviation is often but apparent ; its point being nearer one commis- 
sure than the other, the tongue is supposed to deviate from its right 
direction ; but it is the commissure, not the tongue which is affected. 

Paralysis of the tongue whether it consist in the deviation of its 
point, or is apparent from the difficulty in pronunciation and mas- 
tication, constitutes, in all cases, an important diagnostic sign, as 
it is an almost certain index of a cerebral lesion. 

The color of the tongue may be altered either immediately and 
by a change in the color of the organ itself, or mediately, by the 
coat with which it becomes covered. Paleness and discoloration 
of the tongue rarely occur except in cases of chlorosis and anemia. 



SYMPTOMS. 121 

In organic affections of the heart it partakes of the lividity of the 
neighboring parts. 

The coats which form upon the tongue are generally confined to 
its superior surface, and are of various colors. Those most com- 
monly observed are white, yellow, greenish, brownish and black. 
These coats may be thick or thin, tenacious or easily removed, dry 
or moist, of uniform or unequal extent, disposed in patches, or 
presenting undulations analogous to those observed on geographical 
charts. These coats, it would appear from the chemical analysis 
of Vauquelin, Laugier and M. Denis, have the same origin with 
the dental tartar. According toothers, they are formed by the 
drying of the salivary fluid. 

Whenever the surface of the tongue presents one of the above- 
mentioned coats, some morbid condition generally exists. I say 
generally, for there are many persons in whom abstinence alone 
produces a whitish coat ; and in others, this is constant at all times 
in the day, although their health, in other respects, is perfectly 
good. There are others, as we have before mentioned, who, being 
obliged to sleep with the mouth open on account of the natural 
straitness of the nasal fossae, awake with a dry and often yellowish 
tongue. With these exceptions, a coated tongue almost always in- 
dicates disease. There are others in whom the superior surface of 
the tongue receives and preserves the color of the food and drinks 
taken, becoming of a dark livid hue by the contact of red wine, 
and colored drinks and food generally, as syrups prepared from 
red fruit, chocolate, &c. But this aptitude of the tongue to receive 
and retain coloring matters rarely occurs except in disease, when 
the villosities of the organ become impregnated with the colors with 
which they are brought in contact. 

Are we to believe with the physicians of antiquity that the state 
of the tongue is a true index to that of the stomach ? Is it true 
that a yellowish, or greenish coat upon the tongue, is indicative of 
bile in the stomach ; that a blackish coat should cause us to fear 
the presence of putrid matters in the digestive passages ? Lastly, 
are we to suppose with Broussais, that redness of the tongue is a 
pathognomonic sign of gastritis ? Accurate observation has long 
since shown the entire inconsistency of these various assertions 
with facts. Thus, it was found by M. Louis, in analyzing a great 
number of cases, in his researches on phthisis, that redness of the 
tongue existed in an equal number of patients in whom the stomach 
was found healthy, with those in whom this organ presented a 
grave lesion. The researches of the same author upon typhoid 
fever led to nearly the same results as to the state of tongue in the 
course of that disease. Indeed, whatever aspect this organ pre- 
sented, no correspondence between it and that of the stomach 
could be detected, being the same in those cases in which there 
was a grave lesion of the mucous membrane of the stomach, as in 
those which presented a healthy appearance. According to the 
skilful observer whom we have just cited, the blackish color, 
11 



122 SYMPTOMS. 

roughness and cracked appearance of the tongue, are chiefly owing 
to the intensity of the febrile action, whatever be its cause. 

The tongue may preserve its natural moisture and supple- 
ness, although its surface at the same time be covered by white, 
yellow, or greenish coats ; but is constantly dry, or clammy, 
when loaded with a blackish, or brownish fur. Dryness of this 
organ is more or less considerable ; it may be also partial or gen- 
eral. When existing in a slight degree, it is only apparent from 
the sensation experienced by the patient, and a kind of noise which 
accompanies the motions of the tongue, and which is owing to the 
detachment of this organ from the parts of the mouth, particularly 
the mucous membrane of the palate, to which it was adherent. 
The finger placed upon the tongue and drawn slowly over its sur- 
face, seems to be gently retained by a viscid substance. This is 
rather a simple diminution in the degree of moisture, than a state 
of dryness. In a more advanced stage, the coating is more viscid ; 
the tongue in this case is said to be pitchy (poisseuse). Lastly, 
when this phenomenon is still more marked, the organ is com- 
pletely deprived of moisture. Dryness of the tongue sometimes 
occurs only during sleep, disappearing when the patient awakes, 
or after he has taken liquid food ; at other times, it continues dur- 
ing a part of the day, or for several days. In the latter cases, it 
becomes also smooth, shining and red, or rough, wrinkled and 
black. This condition of the tongue, in acute diseases, is generally 
indicative of danger. If it occur in the course of a chronic disease 
it almost always announces approaching death. 

A phenomenon of great importance in semeiology, is the ex- 
istence of whitish and yellow patches or pimples, often confluent, 
sometimes disposed in the form of a pvltaccous coat, and some- 
times in thin and reticulated, or thick and opaque membranes, 
which are alternately detached and reproduced, generally appear- 
ing simultaneously or successively upon the upper surface and 
sides of the tongue, the internal surface of the cheeks and the 
velum pendulum palati and its pillars. The appearance of these 
patches is of little importance as a diagnostic sign, for it belongs to 
no particular disease, but is of great utility in prognosis. In 
chronic diseases, it is an inauspicious omen, particularly if the 
eruption last beyond a certain number of days, or is reproduced 
many times. In acute affections, though not so grave a sign, it 
may with other symptoms lead us to fear the result. The same 
eruption occurs temporarily, particularly in old persons, without 
any derangement of the health ; its semeiotic value is not the same 
in these cases as when occurring in the course of a grave disease. 

The superior surface of the tongue sometimes presents, particu- 
larly towards its apex, very small red spots, considered by M. 
Roux as a certain sign of the existence of syphilitic virus. We 
only call the attention of observers to this sign, the value of which 
we have not as yet been able to appreciate. The grayish ulcera- 
tions which sometimes appear upon the edges and point of the 
tongue, and which should not be confounded with those occasion- 



SYMPTOMS. 123 

ally produced by inequalities of the teeth, are of syphilitic origin, 
as their appearance indicates. The same may be said of those 
flat, hard, circumscribed tumors of a red or grayish color, from 
two to five lines in breadth, which appear upon this organ, and 
arise from the same cause. 

Lastly, the transverse and often irregular cicatrices which the 
surface of the tongue sometimes presents, should lead us to suspect 
epilepsy, the existence of which is often concealed from the phy- 
sician. This may, consequently, become in some cases a highly 
important sign. 

A change in the temperature of the tongue becomes rarely suffi- 
cient to claim the attention. In the last stages of acute or chronic 
disease, it may become very cold, a sign indicative of approaching 
death. In cholera, the coldness of the tongue was an almost 
constant symptom, and in many cases in which it occurred, 
the patients recovered. It is perhaps unnecessary to add that this 
phenomenon would be without value, if the patient had just 
before taken ice or cold drinks. 

In the course of certain cerebral affections, and in those diseases 
which affect the nerves distributed to the tongue, the tactile or 
gastatory sensibility of this organ may become diminished. From 
the experiments of physiologists, confirmed by pathological obser- 
vations, it would appear that paralysis of sensation is the result 
of a material lesion of the lingual nerve. 

The parts which form the posterior part of the mouth, are also 
the seat of symptoms appreciable to the sight; they may become 
swollen, red, dry, and ulcerated. The velum palati may be de- 
pressed by an abscess in its substance, or by a tumor developed in 
the nasal fossae ; it may be partially destroyed or perforated by 
an ulcer. It has been observed to deviate to the right or left in 
some cases of facial paralysis. The uvula may deviate from the 
median line, become pendent, infiltrated, or entirely destroyed. 
The brown or blackish coat sometimes observed upon other parts 
of the mouth, extends also to this ; apthse often manifest them- 
selves here ; and it is generally upon the velum, sometimes upon 
the tongue and inner surface of the cheeks, that those whitish 
patches which occur in the last period of chronic diseases, and 
which announce a fatal termination, appear. 

D. Mastication is often difficult and painful in disease. Odon- 
talgia, swelling of the face, dental caries, rheumatism of the 
tempero-maxillary articulation, fracture of the maxillary bones, 
dislocation of the lower jaw, are all diseases which may render 
mastication impossible. To these may be added, disease of the 
gums, tongue, and cheeks, the integrity of which is necessary to 
performance of this function. 

E. Deglutition appears to be more rapidly performed in some 
acute affections, the patients swallowing the contents of a cup 
presented to them almost instantly ; it is slower and accomplished 



124 



SYMPTOMS. 



with difficulty in nearly all the diseases of the pharynx and 
oesophagus, as angina, paralysis, and schirrus; the existence of a 
neighboring tumor compressing the pharynx or oesophagus, the 
presence of a foreign body in these passages, hysteria, grave 
fevers, diseases of the brain and upper part of the spinal marrow, 
are all affections in which deglutition may become difficult. Diffi- 
culty of deglutition has been designated dysphagia * It presents 
many remarkable varieties. Some patients can swallow liquids, 
but are unable to swallow solid substances ; this is often observed 
in angina ; in other diseases, as paralysis, the deglutition of solids 
can be accomplished, while that of liquids is impossible. These 
opposite phenomena have been satisfactorily explained; in angina, 
the inflamed mucous membrane cannot bear the contact of a solid 
body, while in paralysis the muscles of the pharynx being en- 
feebled in their action, cannot contract with sufficient force, to 
conduct liquids from the mouth to the oesophagus, but can act 
upon a more voluminous and consistent body as the alimentary 
bolus. 

Morgagni^ according to a dissertation of Spies on deglutition, 
speaks of a singular variety of dysphagia observed in an old man : 
this person was able to swallow all kinds of food, but the last 
alimentary bolus remained in the oesophagus till the next meal, 
unless rejected by the mouth, during the interval, in the effort of 
coughing. In the explanation of this phenomenon, Morgagni 
supposed that the action of the muscles of the oesophagus alone, 
was insufficient to force the bolus from the pharynx into the 
stomach, which could only be accomplished by the weight of 
another bolus, together with the contraction of the oesophagus. 
This disorder of deglutition he very ingeniously compared to a 
similar lesion presented by the excretion of urine in old persons ; 
the bladder being incapable of emptying itself completely of the 
urine it contains. 

Deglutition may become impossible from causes analogous to 
those which render it difficult. 

The absolute impossibility of swallowing liquids, together with 
a horror for every kind of drink, constitutes hydrophobia.X a 
symptom which generally occurs in rabies and sometimes in 
typhoid affections and hysteria. When this symptom exists, the 
sight of water, or of any shining body, often occasions convulsions 
almost tetanic in their nature. 

Deglutition may be depraved in two ways : 1, there may be 
continual efforts to swallow, with successive action of the muscles 
destined to this purpose, while the mouth remains empty ; this has 
been observed in elongation of the uvula and some nervous affec- 
tions ; 2, food carried into the posterior part of the mouth, instead 
of being transmitted directly into the oesophagus, may pass either 
into the nasal fossae, as is the case in diseases of the velum, or 

* Jvg, with difficulty; (payw, I eat. 

t De Scdibus et Causis mort., epist. 1, art. 14. 

t ' y(\wij opia, from ivdwQ, water ; (po(io$, fear. 



SYMPTOMS. 



125 



into the larynx, a much rarer and more serious phenomenon, and 
which can only take place in cases of ulceration of the opening 
of the larynx (Archives, Septembre 1839, Memoire de M. Barth), 
or in the agony and in patients who swallow involuntarily. It 
is hardly necessary to add that in cases of ulceration, rupture, or 
wound of the oesophagus, the food may escape from it, and pass 
into the cavity of the chest. 

There is another derangement of deglutition, in which fluids 
poured into the mouth, are carried by their weight alone through 
the oesophagus, producing a sound by their fall into the stomach as 
if poured through an inert tube. This symptom occurs only in 
the moribund. 

F. Stomachal digestion becomes rarely more active under the 
influence of diseases ; in maniacs, however, the action of the 
stomach appears sometimes greater than in health ; but in most 
diseases it is enfeebled, as is apparent from the sense of weight in 
the epigastrium, and the general uneasiness and aggravation of all 
the symptoms after a meal. Patients who take no food often 
experience various phenomena which indicate functional disturb- 
ance of the stomach; as nausea, retching, regurgitations, vomiting 
and epigastric pain. 

1. Nausea consists in a simple desire to vomit, retching 
(vomituritio) in ineffectual efforts to accomplish this object. Both 
these symptoms accompany many diseases, and particularly those 
of the digestive organs. 

2. Under the term subsultus pracordiorum, a peculiar phenom- 
enon has been also described, which consists in a convulsive 
action of the stomach which prevents the admission of more food, 
and the expulsion of what it already contains, notwithstanding 
the efforts of the patient. 

3. Regurgitation (regurgitatio) is the act by which certain 
gaseous or liquid, rarely solid, substances, rise from the stomach or 
oesophagus into the mouth, unaccompanied by the efforts peculiar 
to vomiting. Renvois is the term applied to matters thus rejected. 
Regurgitation may be complete or incomplete, in the one case, the 
substances rising into the pharynx and mouth, in the other, being 
arrested in some part of the oesophagus and again passing into 
the stomach ; it may be rare or frequent ; and lastly, it may 
afford relief to the patient, or cause increased suffering. 

The renvois or substances rejected by regurgitation may be 
gaseous, liquid, or solid : the gases or eructations (ructus) may be 
inodorous, as is observed in nervous diseases ; they may exhale 
the odor of sulphuretted hydrogen {decayed eggs), that of sub- 
stances last eaten, or be slightly rancid (nictus nidorosi),* as in 

* The sense of the word nidorous is not well defined ; it indicates, in its ely- 
mological acceptation, the odor of animal matters in a state of combustion ; but 
most authors have employed it to express a repulsive odor. 
11* 



126 SYMPTOMS. 

indigestion. The liquids which rise into the mouth are sometimes 
insipid; they are sour in carcinoma of the stomach, bitter in 
bilious disorders, and sharp and burning in pyrosis. Solid 
matters rejected by regurgitation almost always consist of the 
remains of the preceding digestion, which have not undergone 
the necessary elaboration. The renvois are generally gaseous or 
liquid ; in some cases regurgitation of both takes place simulta- 
neously. Solid matters are almost always accompanied by a cer- 
tain quantity of liquid. 

In connection with this phenomenon may be mentioned, rumi- 
nation or merycismus* which consists in masticating, a second 
time, food carried into the mouth by a sort of antiperistaltic con- 
traction of the stomach and oesophagus. This affection, upon 
which Dr. Gintrac of Bordeaux has written an interesting treatise, 
is, in most cases, congenital. It however sometimes occurs acci- 
dentally in old persons affected with cerebral disease, in whom 
there is insufficient mastication together with too great ingestion 
of food; in these cases, the food rising into the mouth undergoes 
a second mastication, without occasioning the person trouble or 
inconvenience. 

4. Vomiting (vomitus) is the act by which substances contained 
in the stomach are ejected by the mouth, with effort, and in cer- 
tain quantities. 

Vomiting takes place under various circumstances, and may 
depend upon an affection of the stomach or other parts of the econ- 
omy more or less remote. It has occurred in gastric derangement, 
simple indigestion, gastrites, softening and cancer of the stomach. 
The affections of the various parts contained within the abdom- 
inal cavity, in which vomiting is liable to occur, are inflammations 
and organic lesions of the peritoneum, intestines, liver, kidneys, 
bladder, cellular tissue of the illiac fossae, and uterus, intestinal 
and epiploic hernia, occlusion of the intestines whatever be its 
cause, hepatic nephritic and saturnine colic, and pregnancy. The 
thoracic phlegmasia?, and particularly acute bronchitis, whooping 
cough and tubercles, produce, in the paroxysms of coughing, 
obstinate vomiting; some cases of tonsillitis and pharyngitis, and 
simple oedema of the uvula may produce sympathetic vomiting, 
which may also occur in certain affections of the brain. In ner- 
vous persons, vomiting frequently follows a severe moral or phy- 
sical shock ; various acute diseases, and particularly the eruptive 
fevers, are ushered in by this phenomenon. From the frequency 
of this symptom, and from the numerous affections in which it 
occurs, it becomes highly important for the physician to be familiar 
with all the circumstances connected with it, and the diseases to 
which it belongs. We shall again refer to this subject ill the 
chapter on diagnosis. 

The matters rejected by vomiting, vary in their nature, consis- 
tence, quantity, color and odor. 

* MtjQvxinuo$, rumination. 



SYMPTOMS. 127 

These may consist of the residue of digestion, as in the attack 
of acute diseases, mucus, green or yellow bile, various medi- 
cinal, and, in cases of poisoning, poisonous substances, &c. They 
may consist; 1, of liquid or coagulated blood in haemorrhage of 
the stomach, which is generally symptomatic ; 2, of a brownish, 
black, pultaceous substance, resembling chocolate or coffee grounds, 
in cancer of this organ ; 3, of pus when an abscess opens into 
its cavity ; 4, of faecal matters, when, from any cause, occlusion of 
the intestines has taken place. We saw at the Hotel Dieu a man, 
suffering from articular rheumatism following dysentery, reject, by 
vomiting, a bloody and viscid substance, resembling in appearance 
the sputa in pneumonia. In cholera, the matters vomited resemble 
rice water or whey ; in one case they exactly resembled milk, both 
in color and consistence. Among them are also sometimes found 
lumbrici, hydatids and biliary calculi ; also portions of cysts, false 
membranes or tumors which have been detached from the inner 
surface of the stomach, or some other part of the digestive canal. 

The consistence of these matters, is variable ; they are generally 
liquid, sometimes clear and watery, at others, thick, viscid and 
resembling paste. They are sometimes mixed with a certain 
quantity of gas or solid matters, as in indigestion. Their quantity 
may vary; this, in many cases, it becomes highly important accu- 
rately to ascertain, particularly in the vomiting of pus and blood. 
Their color and odor generally depend upon their nature. 

Some patients while making the most violent efforts to vomit, 
reject nothing but gas, which is generally insipid and inodorous, 
and produced by simple exhalation. This is observed in certain 
neuroses, and particularly in hysteria. In the single case of dry 
cholera, observed by Sydenham, in the autumn of 1669, there was 
evacuation of wind from above and below, without any other 
excretion. 

5. The pain of which the epigastrium is the seat, varies in its 
character, type, intensity, and particularly in its causes. Ot these, 
the principal are, inflammation of the stomach, the presence of 
indigestible or poisonous substances in this viscus, the various 
organic affections peculiar to it, rheumatism of the muscles of this 
region, the constriction of a portion of the epiploon in an opening of 
the linea alba, peritonitis, any affection of the liver or pancreas, an 
acute or chronic affection of the lungs and pericardium accom- 
panied by a frequent cough, leucorrhoea, habitual pressure on the 
epigastrium by tight corsets, hysteria, &c. This enumeration, 
though incomplete, is sufficient to show the error of those who 
refer all epigastric pain to inflammation of the stomach. There 
are few grave diseases which may not be accompanied by epigas- 
tric pain. 

6. Pain in the stomach, of a peculiar character, sometimes 
occurs, to which the term cramp in the stomach has been applied : 
it is compared by patients to the pain caused by cramp in the 
muscles of the leg, and generally produces forced flexion of the 
body forward, during the whole time of its duration. 



128 SYMPTOMS. 

7. There is still another symptom furnished by the stomach, and 
to which authors have not referred. This consists of a peculiar 
sound caused by the fluids and gases contained in this viscus, and 
which may be produced by a slight blow upon the trunk, or rapid 
pressure made with the hand over the epigastric region, and several 
times repeated. This phenomenon occurs mostly in diseases ac- 
companied by distension of the parietes of the stomach, and par- 
ticularly in cancer of the pylorus. It is sometimes met with in 
healthy itidh iduals. 

G. The symptoms furnished by the intestinal canal are less 
numerous and more difficult to distinguish. Among these may be 
mentioned those internal movements, sometimes felt in diarrhoea, 
the commotion and twisting occasionally experienced by patients at 
the commencement of dysentery, those various movable pains, 
of a dull, rather than acute character, sometimes followed by cold 
sweats and fainting, and which have been termed intestinal colic 
or simply colic, occurring in inflammation of different portions of 
the intestinal canal, particularly the colon, lastly, those partial tu- 
mefactions of the abdomen, produced by the gaseous distension of 
some part of the intestinal canal, or by agglutination of the intes- 
tines with each other, &c. These symptoms need only to be 
enumerated. There are some others which should be mentioned 
more in detail ; as borbory gmi, and also those various changes 
which supervene in the course and excretion of matters and in 
the matters themselves. 

1. The term borbory gmi* is applied to the sound produced by 
displacement of the gases contained within the abdomen. These 
noises accompany intestinal disorders and hypochondriasis; they 
are not unfrequently observed in healthy persons, particularly 
females, and, as has been before remarked, are often caused by 
habitual compression of the abdomen. 

2. There is another intestinal sound, somewhat analogous to 
borborygmi, but differing in being more moist and generally more 
circumscribed. We refer to the gurgling (gargouillement), often 
heard in intestinal hernia, particularly while employing taxis in 
its reduction; it is here produced, as in the stomach, and cavities 
of the lungs, by the concussion of liquid or gaseous matters con- 
tained in a cavity. An analogous sound occurs in schirrus con- 
traction and internal strangulation of a portion of the intestines, 
which aids in their diagnosis. But it is chiefly in typhoid fever 
that gurgling, which is confined to the coecal region, and ordi- 
narily accompanied by local pain on pressure, becomes an important 
sign. Of all acute affections, typhoid fever is the only one in 
which this symptom exists, being in this disease almost constant, 
although varying in intensity and duration ; it is owing to a pecu- 
liar alteration affecting the ilio-ccecal valve and the extremity 
of the small intestines which is peculiar to this disease. In 

* BoQ(io(>vyuo<;, from (toypoQVLo), I make a dull noise. 



SYMPTOMS. 129 

obscure cases this phenomenon becomes an important diagnostic 
sign. 

3. The course of alimentary matters through the intestinal 
canal, may be retarded or accelerated, as we shall see hereafter, 
in referring to their characters. Under certain circumstances, in 
consequence of grave and rare lesions of the intestines, the alimen- 
tary matters may arrive at the termination of the intestinal tube, 
without having traversed its whole extent. In the examination of 
the body of an aged woman who died at Salpeteriere, in whom 
there was disease of the gall-bladder, a large communication was 
discovered, which permitted the finger to pass from the duodenum 
into the enlarged gall-bladder, and from the latter into the trans- 
verse colon ; a yellowish mass which filled these three organs 
clearly indicated the course of the alimentary matters. Perfora- 
tions between contiguous portions of the intestine, have been often 
observed, producing similar results. Patients, in these cases, are 
in a condition analogous to that produced by an artificial anus. 

4. The alvine excretion or defecation (alvina excretio, dcfctcatio) 
is the act by which the contents of the rectum are expelled from 
the body. This may be more or less frequent than in the natural 
state, constituting, in one case, diarrhcea {alvus cita), and in the 
other, constipation (alvi obstipatio, alvus compressa). 

These two symptoms are so frequent, that there are few serious 
diseases in which one or the other, and sometimes both succes- 
sively, may not exist. Constipation and diarrhcea sometimes exist 
to an almost incredible degree; some patients have been known to 
have no evacuation for several months ; in others, on the contrary, 
the excretions are so frequent as almost to allow no interval 
between them. We recollect a patient at the hospital De la Charite, 
who was obliged for several days to keep a vessel constantly be- 
neath him : the excretions were so frequent as hardly to allow 
sufficient time for the vessel to be emptied of its contents. 

Constipation, when habitual, and existing within certain limits, 
is not a serious, and often not a morbid symptom. There are 
individuals who do not go to stool oftener than once in eight, ten, 
or even fifteen days, and experience no inconvenience whatever. 
It is otherwise, if constipation supervene accidentally in persons 
not habitually disposed to it, particularly if accompanied with 
other derangements of health ; it is owing in such cases, either to 
a want of action in the intestines themselves, or to some obstacle 
to the course of the faecal matters. In the most aggravated cases of 
this affection, the contents of the distended intestine, which cannot 
be excreted, are rejected by the mouth. To this complex phenome- 
non, marked by obstinate constipation, and the vomiting of the 
contents of the stomach and intestines, the term ileus has been 
applied. This, which the ancients considered a disease, is in fact 
but a symptom, and may be occasioned by all the causes capable 
of producing occlusion of the intestines, as external and internal 
strangulation, invagination, schirrus contraction, tumors situated 
either without or within their cavity, a foreign body, and sometimes, 



130 SYMPTOMS. 

particularly in old persons, a voluminous mass of indurated faeces. 
The latter cause may produce a kind of hectic fever called 
stercoral, and even death. It is important that the physician be 
familiar with all the causes capable of producing constipation, and 
ileus, which is sometimes dependent upon it. 

Defecation may be accompanied with pain in the anus or in the 
abdomen; these pains almost always occur in constipation ; they 
are sometimes absent at the commencement of diarrhoea, but 
often supervene when this affection has lasted for several days and 
the evacuations have become very frequent. In certain diseases 
of the rectum, defecation is exceedingly painful. To this pain is 
sometimes added a constant and ineffectual desire to go to stool 
together with a burning and smarting sensation about the anus ; 
this constitutes tenesmus or epreintes (desidendi conatus), a symp- 
tom peculiar to dysentery. Tenesmus is sometimes followed by 
no excretion, sometimes a small quantity of bloody mucus is 
squeezed out with violent efforts. Tenesmus should not be con- 
founded with the pain excited by the excretion of faecal matters 
in persons affected with haemorrhoids, fissures, or contraction of 
the anus ; in all these cases, the excreted matters are of a healthy 
consistence ; they act mechanically upon the parts, which they irri- 
tate, but the desire of going to stool is only felt at remote intervals, 
and the pain ceases or becomes diminished during the intervals. 
In tenesmus, on the contrary, the pain and desire to evacuate are 
constant, and the excreted matters are either remarkably altered 
or do not exist at all. Tenesmus does not necessarily indicate an 
affection of the large intestine. It sometimes depends upon pres- 
sure exerted upon the rectum, by a tumor in the pelvis, or in the 
uterus towards the close of gestation. Tenesmus in the male 
may be also owing to the presence of a calculus, of greater or less 
size, in the bladder. 

Defecation, under some circumstances, takes place independently 
of the will of the patient. This symptom presents itself under 
various forms: 1, in some cases of diarrhoea, in which the patient, 
thinking to expel wind, involuntarily allows the escape of fluid 
matters ; the same phenomenon frequently occurs in schirrus of 
the rectum ; 2, at other times he experiences a pressing desire to 
evacuate, and the excretion takes place in spite of all his efforts to 
the contrary ; 3, in other cases, it occurs without producing any 
sensation, and sometimes, even without the knowledge of the 
patient ; this happens in violent acute diseases, and towards the 
close of chronic affections. This incontinence of faecal matters, 
has been also observed in affections of the spinal marrow : invol- 
untary discharge of these matters or of flatus, is often the first 
index of these diseases. 

There are some cases in which the excretion of the faeces be- 
comes otherwise deranged ; the faecal matters are sometimes ex- 
pelled from the body, before having traversed the whole length of 
the intestinal canal. Either from the opening of an abscess into 
the intestinal cavity or a wound of these organs, and more fre- 



SYMPTOMS. 131 

quently from the occurrence of gangrene in strangulated hernia, 
there is formed in the place of the wound or hernial tumor, either 
a small opening called a stercoral fistula, through which a part of 
the intestinal contents pass, or a supplementary or artificial anus, 
which gives issue exclusively and uninterruptedly to the fsecal 
matters. 

In some cases, in which the intestine opens into the bladder, 
these matters are expelled mixed with the urine, but being here 
also retained by a sphincter, the patient is in the same disgusting 
condition, as if suffering from an artificial anus. In a very re- 
markable, and perhaps the only, case on record, the faecal matters 
pursued a still more extraordinary course. An old woman was 
admitted to the Hotel Dieu (service of Dr. Husson) in such a state 
of debility, as to be unable to give any account of her complaints. 
All that was noticed was that the bed was continually soiled by 
faecal discharges. Upon examining the body after death, the large 
intestines were found completely filled with voluminous faces, of 
a stony hardness, and which must have been retained for several 
months ; upon further examination, it was ascertained that owing 
to cancerous ulceration, a communication had been formed between 
the large intestine and the fundus of the uterus, and that all the 
faecal matters passed through the cavity of the latter organ and 
vagina, and ran out at the vulva. The specimen was presented 
to me by Dr. Husson, the younger, and it has since been exhibited 
to the students, in the amphitheatre of the Hotel Dieu. 

4. The excreted matters or excrements (faices) present, in dis- 
ease, numerous alterations, according to their nature, consistence, 
quantity, color, odor, form, and the foreign substances occasionally 
found with them. 

These matters may be watery, as in the intestinal flux with 
which Morgagni was attacked, and serous diarrhoea ; they may 
partake of a mucous character, resembling the white of an egg or 
the spawn of frogs, in some cases of chronic colitis ; they are bilious 
in many diseases; their admixture with a Certain quantity of 
chyme, constitutes the casliac flux {fluxus cceliacus)* [chylous 
diarrhosa] ; they consist of half digested food in lientery {lienterici)-\ ; 
they are streaked with blood in some cases of diarrhoea in which 
the stools are very frequent ; blood is uniformly mixed with the 
mucous discharges in dysentery ; it flows pure and liquid from 
the anus, when it comes from the rectum, and particularly in the 
hemorrhoidal flux ; it is black and changed when from the stom- 
ach, as is often observed after haematemesis, in persons affected 
with cancer of this organ. Liquid blood of a blackish color and 
very fetid odor, when discharged from the anus in large quantities, 
and in the course of a continued fever, indicates, almost with 
certainty, the existence of ulcerations in Peyer's patches, and 
becomes in some obscure cases a very important diagnostic sign ; 

* fCoiUta, belly. 

t JtitrttQia, from Hiiog, smoolh, and ivrtQov, intestine. 



132 SYMPTOMS. 

for among all the acute affections peculiar to our climate, typhoid 
fever is the only one in which these haemorrhages occur. Lastly, 
a frequent or continual, and often involuntary, discharge of sanious 
and stercoral matters, is one of the characteristic signs of cancer 
of the rectum, and sometimes of fistula in ano. Finally, this 
excretion may be mixed with pus in chronic inflammation and 
ulceration of the intestines ; it is entirely purulent when an abscess, 
contiguous to the intestinal canal, opens and discharges itself 
into it. 

The matters excreted from the anus may be in a gaseous, 
liquid, or solid form. The faetidity of the gases becomes increased 
in intestinal disorder and putrid fevers ; their quantity becomes 
greater in hypochondriacs, who are relieved by its emission : this 
excretion is sometimes suspended in obstinate constipation ; it is 
painful in inflammation of haemorrhoidal tumors, dysentery, &c. 
Excreted matters are, in some diseases, harder than in health, as 
in cancer of the stomach, and particularly lead colic : in the latter 
disease they form small black hard balls, resembling the excre- 
ment of sheep, and are hence called ovilles.* When liquid, they 
vary in consistence from that of water to that of pulp: in the 
latter case they are termed pultaceous.\ 

The quantity of excreted matters varies, both in each particular 
excretion, and relatively to the number of excretions in a given 
time. At the commencement of dysentery, the quantity of mucus 
expelled is so small as to resemble the sputa, and hardly to stain 
the linen with which it comes in contact. In certain cases of 
diarrhoea following obstinate constipation, and in cancerous con- 
traction of the intestines, a single excretion sometimes furnishes 
several pounds of faecal matter. When the discharges are very 
frequent, as in the dysentery observed by Zimmerman, in which 
some patients went to stool two hundred times in twelve hours, 
the quantity of matter excreted was very considerable. 

The form of the faecal matters, it is sometimes highly important 
to ascertain ; as in cases of cancer of the rectum previous to ul- 
ceration, in which they are elongated, and often flattened into the 
form of a ribbon, and preserving to a certain extent the size and 
form of the intestinal contraction. 

The excretions are sometimes transparent and colorless, common- 
ly opaque, and of a yellow, brownish or greenish, and sometimes 
white, black or red color. The yellow color depends upon the 
quantity of bile they contain. The peculiar color of yellow ochre, 
which they sometimes present in typhoid fever, is thought by Dr. 
Bright to indicate the period when ulceration of the intestines 
takes place. This opinion of the English pathologist has not as 
yet been verified. Fluid alvine discharges, in which occur a greater 
or less quantity of thick and whitish clots, resembling a decoction 
of rice or whey, were characteristic of the Asiatic cholera ; it was 

* Oris, sheep, 
f Puis, pulp. 



SYMPTOMS. 133 

shown by chemical analyses made at Moscow, Warsaw, Berlin, 
London, and Paris, that a portion of the elements of the blood, 
the serum and the salts, were then evacuated by the intestine, 
and that the white flocculi were formed by albumen in the con- 
crete form, which seemed to be in excess in patients affected with 
his disease. 

If the stools be of a deep black color, the presence of blood is 
indicated ; a dark green color depends upon the presence of bile. 
The excreted matters sometimes resemble chocolate or coffee 
grounds, which indicates that sanguineous exhalation has taken 
place in the upper portion of the digestive tube, particularly 
the stomach ; it is owing to blood which has undergone partial 
digestion. 

The peculiar fetidness of the excrements often becomes increased 
in disease ; a cadaverous odor is noticed in adynamic fevers and 
chronic ulceration of the intestines. They exhale the odor of 
anatomical maceration in certain cases of malignant dysentery. 

The feecal matters may contain foreign bodies, formed within 
the body, or introduced from without. They often present mucous 
pellicles or shreds, which appear to be the result of phlogosis of 
the mucous coat, or of gangrene or ulceration of this membrane; 
portions of intestine which have become separated by gangrene 
after intestinal invagination, have been found in them ; also tu- 
mors, biliary or intestinal calculi, different species of worms, &c. 

Foreign bodies from without present the greatest variety : they 
are sometimes substances incapable of affording nourishment ; and 
sometimes, partially digested alimentary matters. Kernels envel- 
oped in their epidermis,* as dry peas, for example, which have 
been retained for several months, have been expelled unchanged. 

The changes which take place in the nature, consistence, quan- 
tity, and color of the excreted matters, do not depend solely upon 
disease, being also the effect of remedies. The influence of pur- 
gatives upon the frequency of the alvine excretions and consist- 
ence of the excreted matters, is familiar to every one. Rhubarb 
imparts to them a yellow and sometimes a reddish color, resem- 
bling water, to which a few drops of blood have been added. 
The preparations of iron give them a black color, probably from 
the formation of a sulphuret of iron ; calomel imparts to them a 
dark green color. Under these circumstances it is important not 
to confound the phenomena of the disease with those produced by 
remedies. 

* De Sedib. et Caus. morb. epist. xxxi. art. 27. 



12 



134 SYMPTOMS. 



SECTION SECOND. 
Symptoms furnished by Respiration. 

In the healthy condition, the respiration is easy, regular, and 
Avithout noise ; its frequency, that is, the number of inspirations 
and expirations in a given time, is relative to the age and condi- 
tion of each individual. The number of respirations is generally 
about thirty -five per minute in the first year of life, twenty-five in 
the second, twenty, at puberty, and eighteen in the adult age. 
It is a little more in females, lively persons and those of small 
stature, than in those in opposite conditions ; this number becomes 
increased in all persons after physical exercise, declamatory efforts, 
profound emotions, &c. The dilatation of the chest in infancy 
takes place principally by the motion of the ribs ; in old age, by 
that of the diaphragm, and, in the adult, by the movements of 
both combined. 

In disease, respiration furnishes numerous symptoms. Having 
first studied those which belong to the alternate movements of 
inspiration and expiration, we shall proceed to consider those 
which are accidental, as coughing, sneezing, &c. 

§ I. Respiration, considered in the alternate movements of 
inspiration and expiration, presents numerous changes in respect, 
1, to the frequency of these movements; 2, their quickness; 3, the 
quantity of air inspired and expired ; 4, the difficulty of respira- 
tion ; 5, its irregularities ; 6, the sound accompanying it ; 7, the 
qualities of the air expired ; 8, and finally, to these phenomena 
should be added those furnished by auscultation, succussion, per- 
cussion, inspection, and mensuration of the chest. 

In order for the physician to appreciate these various changes, 
the patient should either be seated or upon the back ; he should 
wait till the emotion occasioned by his presence shall have passed 
away, and even then avoid the appearance of examining this 
function, since such is the influence of the will, that it ceases to 
act according to its ordinary rhythm the moment it attracts the 
attention of the patient. The most simple mode of accomplishing 
this, is to place the finger upon the pulse of the patient, while 
counting with the watch the number of respirations in the 
minute. 

1. Respiration is frequent, when the number of inspirations and 
expirations is greater, in a given time, a minute for example, than 
in the ordinary condition; it is rare, when the number is less. It 
is only in cerebral affections that rareness of the respiration is 
observed.* Its frequency, on the contrary, is increased in a great 
number of diseases, and especially those of the heart and lungs. 

* Floyer counted as few as seven respirations in the minute, in more than one 
case of asthma ; and Graves has recorded as few as twelve in some cases of 
fever. — Trans. 



SYMPTOMS. 135 

2. Respiration is quick when the movements of inspiration and 
expiration are performed with rapidity ; slow, in opposite condi- 
tions. Quickness and frequency, slowness and rareness, exist 
simultaneously in most thoracic diseases. In some cases, how- 
ever, as in pleurisy, respiration is quick without frequency, or at 
least its quickness far surpasses its frequency ; at other times, it is 
quick and rare, as in the agony, in which the patient at long inter- 
vals makes a rapid but ineffectual effort at inspiration, which is 
succeeded by an interval of repose. 

3. Respiration is full when the quantity of air inspired is 
greater than usual ; small when less, as in pleurisy and peripneu- 
monia. 

The dilatation of the chest, and consequently the quantity of 
air which penetrates the lungs, is not always equal in the two 
sides. Pleuritic effusion, or the hepatization of a lung, is a more or 
less complete obstacle to the entrance of the air into the corres- 
ponding side. If the patient's chest be uncovered, it will be seen 
that, while the movements of one side are in the normal propor- 
tion, the other, which is the diseased side, remains immovable, 
or nearly so. If, instead of examining these phenomena by the 
eye only, one of the hands be placed on each side of the chest a 
little below and outside the nipples, these differences become 
doubly evident, being marked in proportion to the quantity of air 
which the patient is compelled to inspire into one lung, in order 
to the performance of the functions of both. 

4. Dyspnoea* or difficulty of respiration, presents itself under 
various forms. Respiration is simply laborious, when the respi- 
ratory efforts of the patient do not oblige him to remain seated. 
In many cases, it is not experienced by the patient, except after a 
hurried walk, or ascending a flight of stairs. If the dyspnoea 
compel him to retain the sitting posture, it is called orthopnoea,-f 
which is particularly observed in the advanced stages of organic 
affections of the heart, in the paroxysm of suffocation in pulmo- 
nary emphysema and nervous asthma, and in double hydrothorax 
and simultaneous inflammation of the two lungs. When there 
is at the same time danger of suffocation, it is termed suffocating, 
panting dyspnoea ; lastly, there is painful dyspnoea, in which the 
thoracic movements are as it were arrested by the pain experienced 
in executing them, as in pleurisy. High respiration is that in 
which the patient is obliged to remain sitting, as in orthopnasa, 
and to dilate the thorax, by elevating its sides, as in full respira- 
tion. Difficulty of respiration is sometimes so great, that the con- 
tractions of the inspiratory muscles, and particularly those of 
the diaphragm, are as it were convulsive : the chest and abdomen 
are alternately raised, the neck is bent backward, the point of the 
sternum, at each inspiration, is drawn towards the spine, partic- 
ularly in children, and in some cases all the muscles in the body 

* Jvanvoia, from 8v$, with difficulty, and nvta>, I breathe, 
t OQdomvoia, from oQdog, right, and nveui, I breathe. 



136 SYMPTOMS. 

are in a state of spasm, indicative of the anxiety of the patient 
and of his inability to produce sufficient dilatation of the chest. 
Finally, respiration may be completely suspended, constituting 
apncea* Difficulty of respiration presents also this remarkable 
peculiarity, that in some cases, both the inspiration and expira- 
tion are equally difficult, and in others, one of these movements, 
which is always expiration, is performed with a degree of free- 
dom, while the other is very laborious, as is observed in oedema of 
the glottis. 

In some cases of habitual dyspnoea, it is important accurately to 
ascertain the period at which this phenomenon first made its 
appearance, as this knowledge may enable us to determine the na- 
ture of the organic lesion which produces this derangement: it 
appears from the researches of M. M. Louis and Jackson, that dys- 
pnoea which has lasted from infancy, particularly when occurring 
in paroxysms, is an almost pathognomonic sign of pulmonary em- 
physema.! 

5. Respiration is unequal when the quantity of air inspired 
varies in a certain number of successive inspirations ; it is irregu- 
lar when the intervals between the alternate movements of respi- 
ration are unequal, or do not occur in the usual order ; as in 
intermittent respiration, in which the interval between certain 
expirations and the following inspiration, is sufficiently long for 
the performance of an entire respiration ; also in interrupted res- 
piration (interrupta), in which inspiration and expiration, but 
half performed, succeed each other with rapidity, without being 
separated by an interval of repose ; also in broken respiration, in 
which the dilatation of the chest takes place by several inspiratory 
efforts, and its contraction by as many successive expiratory move- 
ments. This respiration resembles that of persons weeping; it 
has been also observed in hysteria, and often in the rigor which 
forms the first stages of intermittent fevers. 

6. In health, a slight and almost imperceptible murmur accom- 
panies respiration; during sleep, there may be more or less 
snoring. In disease, the respiration may become sibilant, sighing, 
plaintive, stertorous, or rattling. Sibilant respiration is charac- 
terized by a peculiar whistling sound, and is sometimes heard both 
in inspiration and expiration, as in the most severe forms of pul- 
monary emphysema, and particularly in compression of the trachea 
by a tumor ; in other cases, as in some anginose affections, it only 
accompanies inspiration. Sighing respiration {suspiriosa) is that 
in which, at intervals, after a full inspiration, prompt expiration 
takes place, accompanied by a peculiar sound, called a sigh. 
Plaintive respiration (Juctuosd) is characterized by groaning which 
accompanies each expiration ; this has been particularly observed 
in phlegmasia? of the chest, and in some grave fevers. A sound like 
that of ajlute, or that produced by a brazen tube, sometimes ac- 
companies inspiration. This symptom is not unfrequently noticed 

* A privitive, nevw, I breathe 

t Mem. de la Soc. Med. d'Observation, p. 186. 



SYMPTOMS. 137 

in croup ; in some cases, but more rarely, expiration is alone sono- 
rous, the sound in the inspiration being obscure. Stertorous 
respiration, is that accompanied by a loud and vibrating sound ; it 
is observed in severe cases of apoplexy, and in the second stage of 
the epileptic paroxysm ; in rattling respiration, this sound is more 
feeble. Stertor differs from snoring in the difficulty of the thoracic 
movements attending the former, and in the place where it is pro- 
duced ; stertor appears to proceed from the trachea and larynx ; 
snoring from the nasal fossae or posterior part of the mouth. 

7. The changes produced by disease in the expired air, relate to 
its temperature, odor and chemical composition. The breath is 
burning in inflammatory fever, cold in adynamic affections and 
cholera. Its odor is sweetish in certain febrile diseases, acid in 
some affections of the stomach. In some cases, this acidity is so 
marked as to impregnate the air of the apartment ; this symptom 
always indicates a grave and generally fatal lesion of the stomach. 
The breath is fetid and nauseous in bilious fevers and gastric 
irritation : it is sometimes alliaceous, or resembles the odor of a 
dead body after maceration, in gangrene of the lungs and certain 
cases of chronic pleurisy with perforation, sometimes even before 
the sputa present this character. It is hardly necessary to remark 
that the odor of expired air does not depend solely upon diseases 
of the respiratory organs; those of the teeth, mouth, nasal fossae, 
and pharynx equally affect it, as in mercurial salivation, scorbutic 
swelling of the gums, membranous pharyngitis and sylphilitic ul- 
ceration of the throat, affections in which the breath becomes 
intolerably fetid. 

Chemistry has furnished physiology with valuable results in 
respect to the changes which the air undergoes in the healthy lungs. 
It is to be regretted that it has not yet afforded an explanation of the 
modifications which are incontestably produced in the various affec- 
tions of the air passages. Inflammatory induration of the lungs, 
the presence of tubercles in this organ, its compression by pleuritic 
effusion, inflammation of its mucous membrane, together with the 
membranous concretions which form upon it in some cases, are 
all affections in which the air that penetrates the lungs, undergoes 
modifications, which it would be interesting fully to appreciate, 
and which certainly differ from those that take place in health : 
unhappily, the researches undertaken by Nysten and some others, 
have as yet thrown little light upon this point in pathology. It 
was remarked by John Davy and afterwards by M. Rayer, that, in 
the cold stage of Asiatic cholera, no change, or almost none, was 
effected in the air, by respiration. * 

8. To these phenomena, which have for a long time attracted 
the attention of physicians, may be added those discovered by 
Laennec, and which are only perceptible by means of an acoustic 
cylinder, called a stethoscope,f or by the immediate application of 

* Gaz. Medical, 1832. 

t From oTtj6o<;, chest, and axontw, I examine. 

12* 



138 SYMPTOMS. 

the ear to the chest. This method of exploration constitutes in the 
first case mediate, and in the second, immediate, auscultation, of 
which Laennec may be said to be the inventor ; for if it be true that 
the application of the ear to the parietes of the chest, and the ap- 
preciation of the sounds there produced, be twice mentioned in the 
works of Hippocrates, it is no less certain that these two passages, 
justly forgotten from their insignificance and obscurity, did not 
lead to the discovery of a method of exploration, which, in a few 
years, Laennec so far perfected, that time has neither added to, 
nor detracted from, the results of his observation.* 

If the ear be applied directly, or armed with the stethoscope, to 
the chest of a healthy person, during inspiration, a very soft sound, 
or murmur, is heard, produced by the entrance of air into the cells 
of the lungs. This sound is not equally distinct in all parts of the 
chest, being most apparent where the walls of the chest are thinnest, 
as in the hollow of the armpits, below the clavicles, and below 
and within the scapulae. It is much louder in children than in 
adults. In the latter, it varies in intensity, independently of any 
lesion of the lungs ; in some persons it is only perceptible during 
rapid inspiration; in others it preserves the characteristics of 
puerile respiration through life. If auscultation be practised dur- 
ing expiration, no sound, in some cases, can be distinguished ; in 
others, a slight murmur is perceptible, but less distinct and of 
shorter continuance than that heard in inspiration. 

In disease, the natural murmur heard during inspiration, may 
be diminished, cease, be increased or replaced by other and very 
different sounds, in a greater or less portion of the chest. 

The respiratory murmur becomes less distinct, at the com- 
mencement of those diseases of the chest, which at a later period 
cause complete suspension of the respiratory sound in the portion 
of lung affected. This suspension occurs in the second and third 
stage of pneumonia, in emphysema, cancerous and tubercular 
degeneration, cysts and other accidental productions developed in 
the pulmonary tissue, effusions of serum, pus, blood or air into the 
cavities. The vesicular murmur may become less distinct, or en- 
tirely suspended, throughout a greater or less portion of the lungs, 
when there is compression of the principal bronchus, by a tumor 
in the thorax. This is sometimes observed in cases of aneurism 
of the aorta, and this symptom may indicate the direction in which 
the tumor is developed. In some of these diseases, the ear can 
distinguish no natural respiratory murmur or sound whatever ; 
this is the case in great pleuritic effusion ; in most other diseases, 
the respiratory murmur is replaced by morbid sounds, to which 
we shall allude hereafter. 

The absence of the respiratory sound in a portion of the chest, 
may be fixed and permanent in the hepatization of pneumonia ; 

* De V Auscultation Mediate, ou Traite du diagnostic des Maladies des poumons 
et du Caeur, fondi principal 'ement sur ce nouveau moyen d ' exploration, par 
R. T. H. Laennec. 



SYMPTOMS. 139 

Laennec observed in some cases of pulmonary catarrh, a transient 
suspension of this murmur in a limited portion of the lungs, a phe- 
nomenon which he attributed to the momentary occlusion of some of 
the bronchial tubes by the mucus secreted by the parts; according 
to him, this absence of the respiratory sound may cease and reap- 
pear alternately, either in the same part or in any other. We 
have never verified this phenomenon, and as the disease alluded 
to by Laennec is a very frequent one, we cannot divest ourselves 
of some doubts as to its production. 

The respiratory murmur sometimes becomes more intense ; thus 
it may acquire, in the adult, the force and tone which it presents 
in children after forced exercise, in certain neuroses, and particu- 
larly when the other lung has become wholly or partially unfit 
for respiration. In the latter case, the respiratory murmur may 
be increased, not only in the healthy lung, but also in the healthy 
parts of the diseased lung. 

In some cases, the vesicular sound does not present its natural 
softness and smoothness, but becomes rude to the ear. Rudeness 
of the respiratory murmur, as it occurs in inspiration and expira- 
tion, is but the first degree of bronchial inspiration, and is observed 
in those affections in which the latter phenomenon becomes after- 
ward apparent. 

This roughness of the respiratory sound is, in some cases, per- 
ceptible in the expiration before becoming so in inspiration ; the 
expiration is often at the same time prolonged. Dr. Jackson, of 
Boston, was the first to call the attention of physicians to this 
subject, and pointed out this phenomenon, when existing at the 
summit of the lungs, as indicative of incipient tubercles. M. 
Andral, in his notes to Laennec's book, and, more recently, M. 
Fournet, have more thoroughly investigated those diseases of the 
lungs, in which the expiration becomes modified either in force or 
duration. These phenomena are important in the diagnosis of 
certain thoracic diseases, at that period of their development when 
the characteristic signs are absent. 

In certain conditions, the soft murmur of respiration is replaced 
by a louder and rougher sound, called bronchial or tracheal respi- 
ration. This is supposed to be produced in the principal bronchial 
divisions, by resonance of the air, which penetrates but partially or 
not at all, into the ultimate ramifications or their terminating vesicles. 

This sound or souffle is particularly audible, if the ear be applied 
over an indurated portion of the lungs or a moderate pleuritic 
effusion. It often proceeds from a dilated bronchus, or from exca- 
vations produced by ulceration of the pulmonary tissue ; in the 
latter case it is called cavernous respiration. 

This last variety of sound is generally more superficial and 
circumscribed than ordinary bronchial respiration. It is particu- 
larly observed beneath the clavicles, in the supra and infra spinous 
fossae and in the axillae. It is sometimes intermittent, the cavity 
being occasionally filled with liquid, or the bronchial tube, com- 
municating with it, being obstructed by mucus. 



140 SYMPTOMS. 

Under the name veiled souffle [souffle voile], Laennec has de- 
scribed a variety of blowing respiration, which is heard in a pul- 
monary cavity, in which it seems as if each vibration of the 
voice, cough or respiration, agitates a sort of movable veil 
interposed between the cavity and the ear of the observer. Laennec 
pointed out this phenomenon as occurring in those tubercular 
cavities, whose walls are thin and not adherent to the chest, 
abscesses of the lungs while surrounded with an inflammatory 
induration, and some cases of dilated bronchi ; this phenomenon, 
according to him, is very common in pneumonia, when the tissue 
surrounding the bronchus from which the sound proceeds, remains 
healthy or has suffered but slight engorgement. But the veiled 
souffle of Laennec is not so frequent as has been supposed, nor has 
it the semeiological value which has been attached to it. It may 
easily be confounded with the other degrees of bronchial sound. 

The last variety of souffle is that called by Laennec the amphoric 
sound, from its resemblance to that produced by blowing into an 
empty vessel with a narrow neck, as a decanter or bottle. This 
phenomenon is produced when the inspired air penetrates into a 
vast hollow cavity in the parenchyma of the lungs, and particu- 
larly when it passes into the cavity of the pleura, through an 
ulcerated lung. 

The different modifications of the respiratory murmur, just in- 
dicated, become increased and diminished with the material lesion 
on which they depend, furnishing the physician with valuable 
signs, by which he is enabled to distinguish a diminution or in- 
crease in the local disorder, when all the other signs, not excepting 
those afforded by percussion, might be insufficient ; the return of 
the respiratory murmur, in pneumonia and pleurisy, for example, 
sometimes indicates the approaching recovery of the patient, 
several days before the disappearance of the flat sound given by 
percussion. 

Auscultation of the chest, besides furnishing the physician with 
the means of appreciating the changes in the intensity of the re- 
spiratory murmur, also enables him to distinguish the different 
sounds ordinarily produced by the passage of air through the 
various liquids which may be contained in the bronchi. These 
various sounds have by Laennec been designated by the term rale 
or rhonchus, which he distinguished into the crepitant, subcrepitant, 
mucous, dry, sonorous and sibilant. 

The crepitant rhonchus or crepitation, is a slight sound heard 
on auscultation, and which has been compared to the crepitation 
of salt when thrown upon hot iron. It is almost exclusively heard 
in inspiration, and does not always entirely mask the respiratory 
murmur, which becomes less distinct at this point. The rhonchus 
which presents the above characteristics only occurs in the first 
stage of pneumonia, and is consequently one of the most important 
signs of this disease.* It is of equal value, when, instead of 

* This rhonchus is also heard in certain forms of pulmonary congestion, in 
cedema, apoplexy of the lungs, and, according to Stokes, in incipient phthisis. It 



SYMPTOMS. 141 

being formed by numerous and distinct bubbles, it conveys to the 
ear a dry, continuous sound, resembling that produced by rubbing 
silk, or tearing a piece of taffeta. The latter is the most accurate 
comparison, and the sound is often designated by the term, bruit 
de taffetas. 

There is another crepitant rhonchus heard in the commencing 
resolution of pneumonia, when the lungs are passing from the state 
of red hepatization (second degree) to simple engorgement (first 
degree). This has been called by Laennec the crepitant rhonchus 
of return or subcrepita?it, being a variety of the dry crepitant, 
rhonchus. It is formed by bubbles, which are numerous, less 
regular, larger and more moist, being more distinct during inspira- 
tion than expiration. It belongs also to capillary bronchitis, being 
particularly evident at the base of the lungs. Some authors have 
regarded this rhonchus as belonging also to pulmonary emphysema; 
but according to M. Louis, it only exists in this disease when com- 
plicated with pulmonary catarrh, and in this case, results from the 
bronchitis, and not from the dilatation of the vesicles. When this 
rhonchus is continuous, confined to one of the scapulae fossae 
or to some point just beneath the clavicles, and does not succeed 
pneumonia, it indicates the presence of tubercles in their softening 
stage. The subcrepitant rhonchus which depends upon this grave 
lesion, ordinarily consists of bubbles which are larger and fewer 
than in the subcrepitant rhonchus of simple catarrh ; they are also 
somewhat ruder in sound, being generally designated by the term 
moist or dry crackling, according to the sensation produced upon 
the ear. This constitutes the first degree of a phenomenon which 
will be hereafter considered, called gurgling (gargouillement). 

The mucous rhonchus consists of still larger bubbles, which are 
more moist and ordinarily more unequal than the preceding ; it 
is produced by the passage of the air through fluids contained in 
the trachea or bronchi, or acccumulated in the ulcerated cavities 
which succeed tubercular softening. This sound is similar to that 
heard in the throats of dying persons. It sometimes exists over a 
large extent of the chest in those affected with pulmonary catarrh, 
and is always confined to one or more circumscribed spots in 
phthisis. It often disappears after coughing, from the displacement 
of the mucus by which it is produced. 

In some diseases, if the ear be applied over some point of the 
chest, a sound is distinguished analogous to that produced by the 
agitation of a liquid mixed with air bubbles. This phenomenon, 
which in its lightest form may be easily confounded with the mu- 
cous and subcrepitant rhonchi, but which is easily distinguishable 
from these when strongly marked, has been termed gurgling or 
the cavernous rhonchus. It is chiefly heard at the summit of the 
lungs, and is a certain sign of cavities arising from tubercular 

is a curious fact, mentioned by Hourmann and Dechambre, that in old persons 
the bubbles which produce this rhonchus are larger, owing to the increased size 
of the pulmonary cell, caused by the absorption of the intercellular tissue. 
— Trans. 



142 SYMPTOMS. 

softening. It may also exist, though more rarely, in dilatation of 
the bronchi and in the cavities produced by circumscribed gangrene 
or pulmonary abscass, but generally in such cases so differing in 
situation and extent, as not to lead to error in the diagnosis. In 
order to the production of this sound, the cavity should not only be 
entirely filled with liquid, but in extensive communication with 
the bronchi. It is chiefly audible when the patient coughs, or 
draws a full and deep inspiration. 

Gurgling is, in most persons, heard over a circumscribed and lim- 
ited space, one or two inches in size, for example. In cases where 
it is perceptible over a greater extent, it commonly varies in inten- 
sity and form, at different points, and the cause of this is easily 
explained ; this phenomenon being almost always produced by the 
agitation of air with a liquid in ulcerated cavities following tuber- 
cular softening, and these cavities being often numerous and vary- 
ing in their size and form, in the quantity and consistence of the 
fluids which they contain, and the different conditions of the open- 
ing by which they communicate with the bronchial tubes, the 
sounds resulting from this agitation must vary at different points 
within a short distance of each other. 

There are, however, some cases in which a manifest gurgling 
is distinctly audible, over the vriiole of one side of the chest, together 
with a dull sound on percussion, the gurgling being everywhere 
the same as to its intensity and form. The diagnosis, in the first 
case of this kind that I observed, was so obscure, that I hesitated 
in giving an opinion. The patient had, at first, presented all the 
signs of a considerable pleuritic effusion ; dull sound, absence of 
respiratory murmur and vocal resonance, together with dilatation of 
the diseased side. When I saw him, a month afterwards, the dull 
sound still continued ; but to the ear, applied successively in front, 
behind, above and below, a gurgling sound was everywhere dis- 
tinguishable, the same in form and degree, as if the pulmonary 
tissue had been entirely transformed into a multitude of ulcerated 
cavities, all presenting similar phenomena, and consequently ma- 
terial conditions exactly identical, a circumstance which, without 
being strictly impossible, was entirely inadmissible. This young 
man after leaving Paris died in the provinces; no examination 
after death was made. 

I again observed this gurgling, uniform in rhythm and intensity, 
together with a dull sound on percussion, over the whole of one 
side of the chest, in a patient at La Charite. This man rejected 
by the mouth, a few days after his entrance into the ward St. Jean 
de Dieu, more than a pound of fetid pus, which must have come 
from the cavity of the pleura. This second case afforded me the 
explanation of the former, and led me to suppose that an excava- 
tion formed in the pulmonary tissue, opening into the bronchial 
cavity, and situated just beneath the pleura, the cavity of which 
is filled with pus, may, under some conditions not yet with cer- 
tainty determined, if a thin pellicle alone intervenes between the 
ulcerated cavity of the lungs and the pus contained in the pleura, 



SYMPTOMS. 1 43 

or if there exist a valvular opening preventing the passage of air 
into the pleura and the production of pneumothorax, give rise to a 
phenomenon as remarkable as that observed in the two cases just 
alluded to. The gurgling was probably produced, as it ordinarily 
is, in the tubercular cavity, and thence transmitted to the whole 
periphery of the chest by the liquid contained in the pleura, as, 
under other circumstances, this liquid transmits the voice (ego- 
phony), and the respiratory murmur bronchial respiration.* 

The patient last alluded to, after having vomited pus in abun- 
dance, and at various times, gradually recovered so as to be able 
to leave the hospital. I advised him, should the symptoms again 
present themselves, to return. He, however, finally recovered, at 
least to all appearance. This case, though incomplete, fixed my 
opinion upon the value of this symptom, which I believe has not 
before been pointed out. 

A third case, more recently observed at Hotel Dieu, gave 
farther evidence of the value of this sign. A negro who was ad- 
mitted into the ward Sainte Madeleine, presented symptoms of 
pleuritic effusion, with intense fever : to these phenomena, was 
soon added a gurgling similar to that which occurred in the two 
other cases, being audible over the whole of one side of the chest, 
and everywhere under the same form and with equal intensity. 
A few days after, a large quantity of pus was rejected by the 
mouth. After the death of the patient, we were able to ascertain 
with certainty, that the cavity of the pleura being filled with pus, 
communicated with the bronchi by means of a tubercular cavity. 
The insufflation of air into the trachea showed the point at which 
the pleura was perforated, and permitted us to trace the fistulous 
track to one of the bronchial divisions. 

In these three cases only, have I observed this form of gurgling 
with the conditions described, and in all these the disease com- 
menced in the same manner, by a pleuritic effusion. 

I have twice observed a form of gurgling somewhat analogous 
to that in the preceding cases, from which it should be distin- 
guished. 

A patient was admitted to the Hotel Dieu for a chronic affection 
of the chest, who presented, independently of the cough, opaque 
sputa, dyspnosa, and the other ordinary phenomena of hectic fever, 
a dull sound over the whole anterior part of the left side of the 
chest. At whatever point of this portion the ear was applied, 
gurgling was audible ; this gurgling, as in the three other cases, 
was everywhere the same as to form, but its intensity, instead of 

* The co-existence of a pleuritic effusion with tubercular cavities in the lungs 
is by no means rare, although the kind of gurgling which I have pointed out has 
only been observed in a very few cases ; it is necessary then, in order to the 
production of this phenomenon, not only that this complication exist, but that it 
should exist under peculiar conditions, without which it could not take place. 
This phenomenon appears to me a certain sign of the simultaneous existence of 
the two lesions just indicated ; but its absence by no means proves the non-exis- 
tence of this complication. 



144 SYMPTOMS. 

being the same wherever the dull sound existed, progressively- 
diminished from the summit of the thorax where it was very man- 
ifest, to a point below the heart where it became obscured. I was 
led to suspect in this patient a lesion analogous to those which ex- 
isted in the three others, but confined to the anterior part of the 
chest, in short, a partial effusion into the pleura with perforation 
of the pulmonary parenchyma about to take place, or already 
completed. The exceeding rareness, however, of pleurisies con- 
fined to this region, and the progressive diminution in the gurgling 
sound from the summit towards the base, caused me to be circum- 
spect in the diagnosis. After death, we found at the summit of 
the left lung, a collection of small tubercular cavities, in an extent, 
of the size of a pullet's egg, the rest of the anterior portion of the 
pulmonary parenchyma being indurated and presenting a grayish 
appearance. In this case the gurgling had evidently been pro- 
duced in the ulcerated cavities at the summit of the lung, and the 
sound had been transmitted by the indurated lung, and in the 
whole extent of the induration, with the progressive diminution in 
intensity, above mentioned. I had occasion to observe in another 
case, under analogous anatomical conditions, the same phenome- 
non, but less marked and heard over a less extent. 

It follows from these cases that a similar sound, heard over a 
great extent, or over the whole of one side of the chest, should lead 
us to suspect two distinct lesions, the one which gives rise to the 
production, the other to the transmission, of the gurgling. The first, 
generally consists of one or more ulcerated cavities in the pulmo- 
nary parenchyma, the second, in induration of the lung, or pleu- 
ritic effusion. If the gurgling be perceptible over the whole of one 
side of the chest, with the same form and intensity, its transmis- 
sion depends upon a pleuritic effusion ; it is owing to pulmonary 
induration, if the sound, the same as to its form, progressively di- 
minishes in intensity over the extent in which it is heard. In the 
latter case, the transmission is almost always confined to a part of 
the chest ; in the former, it ordinarily extends over its whole side. 

The sonorous rhonchus is a dull sound, sometimes extremely 
loud, which at one time resembles the snoring of a person asleep, 
at another, the base note of a violincello, and occasionally the 
cooing of a pigeon. This phenomenon must not be confounded 
with the guttural sound produced by some persons when asleep, 
and which any one may imitate at will. The latter is produced 
in the throat; that which we are now considering, proceeds 
from the chest, and is only perceptible by auscultation. It seems 
to depend upon a change in the thickness and humidity of the 
bronchial mucous membrane. 

The sibilant rhonchus commonly resembles a prolonged whistle, 
low or acute ; sometimes, the chirping of small birds, the sound of 
a pump, or the clacking of a valve. It appears to be owing to a 
small quantity of very viscid mucus which partially fills up the 
bronchial ramifications, or to swelling of the mucous membrane. 
These two varieties of the dry rhonchus, but particularly the 



SYMPTOMS. 145 

latter, occur in acute or chronic pulmonary catarrh, and at every 
period of the disease. These rhonchi, both the sibilant and sono- 
rous, are heard over almost the whole extent of the chest in patients 
with typhoid fever; they are louder, and audible over a greater 
extent, than in bronchitis, although there is less dyspnoea than in 
the latter affection. 

Independently of the sound perceptible to the ear in the various 
kinds of rhonchus, there sometimes exists, particularly with the 
sonorous rhonchus, a sort of trembling, perceptible to the hand, in 
that portion of the chest corresponding to the part affected. When 
the lesion which produces the rhonchus is deeply seated, this 
trembling is not so distinct ; the absence of this phenomenon be- 
comes then a sign which may aid in determining the particular 
seat of the disease. 

There is another variety of sound, differing from the rhonchus, 
which may be distinguished by auscultation during the respiratory 
movements, and still more easily if the patient speaks or coughs. 
This sound, called by Laennec metallic tinkling, resembles that 
emitted by a plate of glass or metal when gently struck with a hard 
body. This phenomenon has only been observed in patients with 
ulcerated cavities in the lungs or pleuritic effusion. In both cases, 
it appears indispensable to its production, that the cavity contain 
a liquid together with air, and that it communicate with the bron- 
chi. According to Laennec, this sound is produced by the reso- 
nance of air agitated at the surface of the liquid, or the falling 
of a drop of fluid from the summit of the cavity into the fluid 
collected in the under part of it. Other physicians (M. M. Dance 
and Beau) have endeavored to explain this phenomenon by sup- 
posing that in the act of speaking, coughing or breathing, air 
escapes through the pulmonary fistula into the liquid effusion, 
and rises to its surface in the form of bubbles of a greater or less 
size, which, in breaking, cause a vibration in the air above, thus 
producing the resonance which constitutes metallic tinkling. * 

* However satisfactory the explanations which have hitherto been offered 
to account for this curious phenomenon, none has as yet been found to hold good 
in all cases. 

We have been kindly permitted to quote two cases which fell under the observa- 
tion of Dr. J D. Fisher of this city, as proving the truth of this assertion, and 
illustrative of the ingenious theory proposed by him, in accounting for the pro- 
duction of this sound. 

The first was a case of pneumothorax, in which the metallic tinkling was heard 
in its maximum intensity over the right scapula, and at the acme of each respira- 
tion. Upon examination, a communication was found to exist between the bronchi 
and cavity of the pleura by means of a small opening, almost exactly opposite the 
point where, during life, the sound was most distinct, and far above the level of the 
fluid which was in small quantity and of the consistence of thick cream. Upon 
examining this opening, it was found to be covered by a small semi-circular flap, 
apparently formed by a thin lamina of the pleura, about three lines in diameter, 
and which, upon blowing into the trachea, was forced open, a slight click being at 
the same time audible. 

The second case was that of a large cavity in the lungs, with exceedingly thin 
walls, and in which the sound was also heard at the acme of respiration. This 

13 



146 



SYMPTOMS. 



Metallic tinkling is not always the same. Thus, when it takes 
place in a cavity, it is only audible over a circumscribed space, 
while, if symptomatic of pulmonary fistula and pneumothorax, it 
is heard over a great extent. Laennec remarks that this phenom- 
ena is more appreciable, when the fistula is large and the quantity 
of air in the chest very considerable. 

The metallic tinkling generally coincides or alternates with am- 
phoric respiration. Great respiratory efforts render them more 
manifest, and may reproduce them when not permanent. 

There is still another phenomenon which we shall point out, not 
without importance as a diagnostic and prognostic sign ; we refer to 
thoracic succussion, a method of exploration employed by Hippo- 
crates, and clearly pointed out in his works, but the semeiological 
value of which he did not fully appreciate. This method consists 
in forcibly shaking the patient's chest, while the ear is placed near 
this cavity : the sound of fluctuation is then distinctly heard, some- 
times extending to the assistants at a distance, and the patients 

sound was produced after the death of the patient, by blowing through the trachea. 
In this case, as in the other, the cavity was found to contain but little fluid, and 
the bronchial opening, which was of considerable size, existed aboiie its level, its 
truncated portion being remarkably smooth. This opening was only discoverable 
by blowing into the trachea, when, as the air passed into the cavity, the walls, 
which were previously in close contact, and, as it were, glued together by the 
viscid secretion of the part, were seen suddenly to separate with a sound almost 
precisely similar to that produced during life. 

It would appear then that, at least, in these two cases, the principal condition 
necessary to the production of the metallic tinkling, according to the theory of 
Dance and Beau, and the experiments of Fournet, Bigelow and others, viz. the 
existence of an opening below the surface of the fluid, was absent. The theory 
of Laennec would also seem, in these cases, insufficient to explain this phenome- 
non, as the sound occurred at regular intervals with each respiration, the patient 
being in a state of rest. 

In order to the farther elucidation of this point, Dr. Fisher made the following 
experiment, which seems fully to confirm the views which he had previously enter- 
tained. 

Having inserted an elastic flexible tube into the neck of a distended bladder, 
upon blowing into it, the amphoric resonance was distinctly heard. He now poured 
a thick solution of gum arable into the tube, to render the conditions, as nearly as 
possible, similar to those in the above mentioned cases, when upon again blowing 
into it, a click exactly resembling the metallic tinkling was distinctly heard. 

He concluded, from these observations and experiments, that if an unobstructed 
opening into a large cavity, exist, amphoric resonance will be produced, while if 
there be, in this opening, any impediment to the passage of the air, as viscid mu- 
cus, or, as in the first case, a valvular formation, which suddenly yields, the me- 
tallic tinkling is the result. 

The following, then, are the conditions which, according to Dr. Fisher, are 
necessary to the production of this sound; 1, a cavity of considerable size with 
thin walls ; 2, a communication between this cavity and the bronchia, by an open- 
ing in which there exists some obstruction which suddenly yields to the force of 
the air. 

Without denying the possibility of the occurrence of this sound under the con- 
ditions hitherto considered necessary to its production, it must be admitted that 
there are cases in which these conditions entirely fail, and in which some other 
explanation must be sought. The theory proposed by Dr. Fisher affords a satis- 
factory explanation of this sound in cases which are inexplicable by any other, and 
may be found to account for its production in nearly all cases. — Thans. 



SYMPTOMS. 147 

themselves often perceiving it when executing any movement, as 
descending a staircase, examples of which are related by Ambrose 
Pare, Willis, Morgagni, Boyer, &c .* This sound, regarded by 
Hippocrates as a sign of serous effusion in the chest, is never 
heard in simple hydrothorax ; it only occurs in cases in which the 
pleura contains liquid and air together, and is sometimes produced 
when an enormous hollow cavity in the lungs exists. As we have 
seen, metallic tinkling, amphoric respiration and the hippocratic 
fluctuation, are phenomena equally characteristic of a determinate 
alteration ; wherever any one of these exist, the prognosis must be 
grave, since it reveals the existence of pathological conditions 
almost necessarily fatal. 

Thoracic fluctuation should not be confounded with an analo- 
gous sound sometimes produced in the stomach when the body is 
shaken, the stomachal gurgling which has been before alluded to : 
it is sufficient to be warned of this error in order to guard against 

Independently of these sounds that we have just considered, 
and all of which are owing to the passage of air into the natural 
or accidental cavities, there is another which depends upon the 
friction of serous surfaces against each other. This sound has 
been described by Laennec, under the term, ascending and de- 
scending murmur (murmur ascensionis et descensionis). 

But Dr. Reynand was the first who thoroughly investigated 
the anatomical conditions which give rise to this sound and as- 
certained its true value as a diagnostic sign. In the ordinary act 
of respiration, during the alternate movements of elevation and 
depression of the thoracic parietes, there is a rubbing of the pul- 
monary against the costal pleura; but owing to the smoothness 
and moisture of these surfaces, no sound is probably produced, or 
if it exist, it is confounded with the natural murmur of respiration. 
But when more or less roughness or inequality exists, produced by 
false membranes adherent to the surface of the pleurae, a rough 
friction sound, like that of rumpled parchment, a file, or new leather, 
accompanying both respiratory movements, but particularly that 
of inspiration, is audible at a point corresponding to this lesion. 
In some cases, by applying the hand over this part, a peculiar 
and characteristic tremor is perceived. The friction sound may 
occur at the commencement of dry pleurisy, or towards the termi- 
nation of pleurisy with effusion, when, in consequence of the 
reabsorption of the fluid, the two opposite surfaces of the pleura, 
covered with false membranes, come in contact. Laennec was 
probably wrong in attributing the ascending and descending fric- 
tion sounds to interlobular emphysema of the lungs. 

Besides these phenomena furnished by means of thoracic aus- 
culation, there are others occurring in rare diseases, that have 
not yet been observed since this mode of exploration became 
known, which it cannot fail to reveal. 

* Laennec, torn. ii. p. 587 ; 4 e edition. 



148 



SYMPTOMS. 



In hernia of the lungs through the intercostal muscles, for ex- 
ample, the application of the stethoscope over the tumor would 
undoubtedly enable us to hear the entrance and egress of the air, 
thereby adding a new sign to the diagnosis of this affection. In 
cases in which borborygmi are audible above the region of the stom- 
ach, the existence of hernia of the stomach or intestines through 
the diaphragm, might, according to Laennec, be safely inferred. 
This certainty, however, cannot exist until an assertion, which is 
probable, but the truth of which is not yet demonstrated, shall 
have been confirmed by experience. The varieties presented in 
the concavity of the diaphragm, and those which exist, conse- 
quently, in the position of the stomach, the facility with which 
sounds are transmitted to a certain distance, the peculiar noise pro- 
duced by the rising of the air from the stomach into the cesopha- 
gus, appear to us to justify the doubts that we have entertained in 
respect to the pathognomonic value of this phenomenon. 

Auscultation of the voice furnishes the diagnosis of thoracic dis- 
eases with certain phenomena interesting to the observer, and 
very useful in a diagnostic point of view. When a healthy man 
speaks or sings, his voice generally produces over the whole extent 
of the thoracic parietes a kind of vibration perceptible to the hand. 
If the ear, or stethoscope, be applied to the chest, this vibration is 
less apparent ; but a remarkable resonance is observed, particularly 
in those regions where the soft parts are thinnest, or those corres- 
ponding to the larger bronchi more or less superficially situated. 
Thus, this vocal resonance is particularly apparent in the axillae, in 
the superior and anterior regions of the chest, in the interscapular 
space, and at the superior and internal angles of the scapulas, partic- 
ularly the right, the lung of that side being more voluminous and 
the bronchus larger. This natural resonance of the voice is want- 
ing in some persons ; in others, it is hardly perceptible ; it is par- 
ticularly observed in those who have a deep, sonorous voice, and 
full chest. In disease, this resonance undergoes important modi- 
fications ; it may be diminished, completely cease, or be replaced 
by other phenomena, known as bronchophony, aegophony and 
pectoriloquy. 

The natural vibration of the thoracic walls is generally dimin- 
ished in hepatization of the lungs ; it entirely ceases in cases of 
pleuritic effusion, so that it is sometimes possible to mark exactly 
the level of the liquid by the point where the resonance begins to 
be again perceptible ; but this phenomenon is of far less importance 
than those we are about to consider. 

Bronchophony * is a resonance of the voice more or less loud and 
diffused, an accurate idea of which may be obtained by applying 
the stethoscope over the larynx of a person while speaking. In 
disease, this phenomenon is produced under the same anatomical 

* Bqoyx ?, bronchus; (pmrj, voice. In accordance with Greek etymology it 
should be written broncophony ; but we have thought that the word created by 
Laennec, and accepted by science should be preserved ; besides, the terms bronchi, 
bronchial, are employed. 



SYMPTOMS. 149 

conditions which give rise to tubal or bronchial respiration, that is, 
in red and gray hepatization of the lungs, pleuritic effusions, and 
pulmonary induration produced by tubercular matter, melanosis, 
&c. When broncophony and tubal respiration depend upon dis- 
ease of the parenchyma of the lungs, these sounds remain the same 
in whatever position the patient be placed. If, on the contrary, 
they are owing to effusion, by placing the patient in different posi- 
tions, these phenomena are rendered more marked, or more obscure, 
and the point where they are produced, if nothing oppose the fall- 
ing of the fluid in obedience to the laws of gravity, may become 
changed. Now, observation shows that this is far from common, 
and that in most cases, in which the effusion has existed but a few 
days, the liquid remains within the same limits, whatever be the 
attitude of the patient. In regard to the theory of bronchophony, 
Laennec thought that it resulted from impermeability of the air 
cells and ultimate bronchial ramifications, and the consequent 
resonance of the voice in the large bronchial tubes. The explana- 
tion of this, as of other phenomena, is a secondary consideration. 
The phenomenon itself and its semeiological value are important 
points, which happily are understood. 

JEgophony, * like bronchophony, consists in increased resonance 
of the voice, but presenting different characteristics. This reso- 
nance is sharp, trembling, or broken, like that of a goat, and 
seems more like the echo of the patient's voice, than the voice 
itself. If this phenomenon occur in a part adjacent to a large 
bronchial trunk, towards the root of the lung for example, in addi- 
tion to a remarkable resonance, and under the influence of these 
two conditions united, the voice presents modifications, resembling 
that produced by a counter placed between the teeth and lips of a 
person while speaking, or bredouillement* which constitutes the 
language of Punchinello. /Egophony may be perceptible in nearly 
all parts of the chest ; but it is heard particularly between the 
spine and scapulae, around the latter bones, and in a zone two or 
three inches wide, extending between the scapula and nipple. It 
is sometimes distinguishable on the first day ; it however becomes 
more marked in the few days following, and afterwards disappears, 
the effusion being either absorbed or increased. This phenomenon, 
may, like bronchophony, become obscure, disappear, or change its 
place according to the position of the patient, if adhesions do not 
prevent displacement of the fluid. 

Laennec ingeniously explained the phenomenon of segophony. 
by supposing it to be produced by the vibration of the voice, 
transmitted through a thin and trembling layer of fluid. The 
same author also remarked that a pleuritic effusion by compres- 
sing the bronchial tubes, flattens them like the mouthpiece of a 

*Ai%, atyog, goat; <pwv!j, voice. 

f A precipitate and indistinct mode of utterance, in which a part of the 
words only is pronounced, and several of the syllables viciously changed. It is 
analogous to stuttering in some respects. — Tr. 

13* 



150 SYMPTOMS. 

bassoon or hautboy, instruments which produce a bleating sound. 
The false membranes which sometimes cover the surface of the 
pleura, have also been supposed to give rise to the same phe- 
nomenon. 

Whatever be its explanation, we cannot grant to this phenomena 
all the importance attributed to it by Laennec, and consider it as 
a pathognomonic sign of pleuritic effusion ; for, on the one hand, 
there are many healthy persons in whom segophony exists, 
as Laennec himself admits ; and on the other, it has been 
noticed in cases of hepatization of the lungs, as has bronchophony 
in some cases of pleuritic effusion. If, however, eegophony be 
not pathognomic of effusion, it should certainly lead us to suspect 
its existence. It is sometimes difficult to distinguish between 
aegophony and bronchophony ; they often exist together, a circum- 
stance which has led to the term broncho-segophony. 

Pectoriloquy* consists in a peculiar resonance of the voice, 
which, in mediate auscultation, seems to issue directly from the 
chest of the patient, and pass through the central canal of the 
stethoscope; if the physician employ immediate auscultation, it 
appears as if the patient were speaking in his ear. 

Laennec distinguishes several varieties of pectoriloquy, which 
he severally terms perfect, imperfect, and doubtful. The first is 
alone of any real value. The two others, rather resemble bron- 
chophony, or the ordinary resonance of the voice. They may be 
distinguishable, in the healthy state, in certain parts of the chest, 
particularly at the summit, and as far as nearly to the third rib. 
But that circumscribed and distinct resonance of the voice, which 
constitutes pectoriloquy, should be considered as pathognomonic 
of a hollow cavity in the lungs, whether it be owing to a simple 
dilatation of a bronchus, partial suppuration of the lungs, or, as 
generally happens, to tubercular softening. 

In order to the occurrence of pectoriloquy, the existence of a 
well defined superficial hollow cavity in the lungs, of medium 
size, that of a nut or small pullet's egg, for example, with hard- 
ened walls, is necessary ; the cavity should be empty and commu- 
nicate freely with the bronchi ; there must be absence of aphonia, 
which is a frequent symptom in the last stage of phthisis, as if 
this exist, pectoriliquy cannot be produced. The phenomenon 
fails, or is less perfect, if the cavity be filled with a liquid, be 
too large or irregular in its shape, and communicate with the 
bronchi by means of small openings alone, which are not in pro- 
portion to the size of the cavity. In general, pectoriloquy is more 
apparent when the voice is sharp, than when low or hoarse. This 
phenomenon disappears and returns alternately in some persons : 
this intermittence is generally owing to the transient occlusion of 
the cavities or of the bronchial tube which communicate with it. 
Gurgling often accompanies pectoriloquy, and adds to its value as 
a sign. 

* From pectus, breast ; loqui, to speak, 



SYMPTOMS. 151 

Percussion, as well as auscultation of the chest, furnishes many- 
important signs, which we shall now proceed successively to con- 
sider. 

In disease, the sound of the chest, on percussion, may be clearer 
than natural, more dull, or entirely flat. The sound becomes clearer 
whenever the quantity of air in the chest becomes increased, and the 
nearer this fluid is to the point percussed ; this is the case m pneu- 
mothorax and pulmonary emphysema. In the first of these affec- 
tions the chest sounds like a drum over a greater or less portion of 
its extent ; in emphysema the sound is less clear in pneumotho- 
rax, but clearer than in the healthy state. In both affections, the 
clear sound may be confined to a limited space, or it may extend 
over the whole of one side in pneumothorax, and over both in 
emphysema. In one of these diseases the excess of resonance is 
owing to the presence of air in the pleura ; in the other, to its 
accumulation in the dilated pulmonary vesicles. A sound clearer 
than natural may also be elicited, when percussion is practised 
over a large empty cavity superficially situated. If the cavity 
be partially filled with a fluid, and the thoracic walls be thin and 
elastic, the sound on percussion is that called by Laennec le bruit 
de pot fele, the sound of the cracked pot, in which the resonance 
of a cavity with gurgling is distinguished. This has as yet never 
been observed except in phthisical patients, just beneath one of the 
clavicles. 

The sound of the chest becomes obscure or dull, whenever the 
lung is indurated, or when a solid or liquid body interposes be- 
tween this viscus and the thoracic parietes at the point percussed. 
The sound of the chest is slightly diminished in pulmonary con- 
gestion, the first stage of pneumonia, and some cases of tubercles 
before becoming united into a compact mass, and in slight effu- 
sions of liquid. It is completly flat (tanquam percassi femoris) in 
all cases of pulmonary induration, in rare cases of tumors within 
the chest, and finally, in liquid effusions so abundant as to press the 
lungs backward towards the vertebral column. In the latter case, 
by varying the position of the patient, it might be possible to alter 
the results of percussion, if the effusion were partial, and there 
were nothing to prevent the fluid from obeying the laws of gravity. 
Nothing of this kind is observed when the dull sound is owing to 
pulmonary induration, or the presence of a tumor. 

In enumerating the causes which produce a dull or obscure 
sound of the chest on percussion, we have not referred to the 
adhesions of the costal with the pulmonary pleura, as, in our 
opinion, they have no part in producing this effect. To be con- 
vinced of this, it will be sufficient to recall those cases of phthisis, 
in which the chest sounds clear over almost its whole extent, 
although the adhesions are stronger, and a more constant symptom 
in this than in any other disease. Adhesions do not affect the 
resonance of the chest, unless there be serous or gelatinous infil- 
tration into the cellular network of which they are composed. 

Whenever the sound elicited by percussion is flat or even 



152 SYMPTOMS. 

obscure, that peculiar elasticity which is always felt in percussing 
a healthy chest, is no longer perceptible. There is, on the con- 
trary, a feeling of hardness or resistance, which is in proportion to 
the density of the body producing the dullness. 

The rules relating to the employment of auscultation and per- 
cussion, together with the semeiological value of the phenomena 
furnished by these two important methods of exploration, will be 
considered in the chapter on diagnosis. 

§ II. Respiratory phenomena. Having now presented the prin- 
cipal symptoms furnished by the respiration itself, we shall pro- 
ceed briefly to consider some of the respiratory phenomena, as 
laughing, yawning, sneezing, hiccough, coughing, exspuition, and 
expectoration. 

1. Laughing {risus) consists in an interrupted expiration, ac- 
companied with a cheerful expression of the features, and partic- 
ularly retraction of the lips. This is a phenomenon peculiar to 
health, rather than a symptom of disease. There are, however, 
many affections in which it occurs under the latter form, depending 
either upon the state of the mind, as in the delirium of acute dis- 
eases and certain forms of mental alienation, or upon a special 
derangement of the nervous system, as in hysteria, and, as some 
have asserted, in wounds and inflammation of the diaphragm. 

2. In yawning (oscilatio) there is suddenly a deep, slow, and 
sonorous inspiration, with separation of the jaws, and accompan- 
ied with flexion, followed by the slow and gradual extension of 
the limbs, and particularly the arms. This latter movement, 
called pandiculation {pandiculation sometimes occurs without the 
yawning, which it almost always accompanies. Both these 
symptoms frequently appear at the commencement of the parox- 
ysms in intermittent fever, and towards the close of an hysterical 
attack. 

3. Sneezing {sternutatio) consists in a violent and convulsive 
expiration, by which the air is driven rapidly, and rushes sonor- 
ously, through the nasal fossae, carrying with it the mucus adher- 
ing to these parts. Sneezing, although, like yawning and stretching, 
occurring in health, is a frequent symptom in coryza, and in the 
first period of rubeola. 

4. Hiccough (singultus) is the result of a sudden and involun- 
tary contraction of the diaphragm, accompanied with contraction 
of the glottis which prevents the entrance of air into the trachea. 
This symptom occurs under various circumstances, as in the 
lightest affections, and even in persons in perfect health, and in 
very grave diseases, as, abdominal inflammation, and particularly 
peritonitis, strangulated hernia, and all cases of stoppage in the 
course of faecal matters, in which its appearance confirms the 
diagnosis, and renders the prognosis more unfavorable. 

5. The cough, (lussis) according to physiologists, consists in 
violent, short, and frequent expirations, in which the expired air, 
in passing through the larynx, produces a peculiar sound. This 
is not a correct definition. One of the most constant phenomena 



SYMPTOMS. 



153 



accompanying coughing is a momentary occlusion, or at least, a 
considerable contraction, of the glottis. This contraction does not 
concur alone in the production of the peculiar sound observed ; it 
prevents the egress of air, which afterwards escapes with great 
rapidity, thus more easily, by communicating to it the impulse 
which it receives, carrying with it the mucus adherent to the 
parts in its course. 

Many varieties of cough have been admitted, of which the 
principal are the idiopathic * and sympathetic, moist and dry 
cough. If the exciting cause of the cough be seated in any of 
the air passages, it is idiopathic : it is called sympathetic when it 
depends upon an affection of some viscus more or less remote. 
The idiopathic cough may be guttural or pectoral, according as the 
irritation which excites it, is above or below the glottis. The 
sympathetic also varies with the organ which causes it. That 
arising from an affection of the stomach, has been called stomachal 
cough : it is said to be dry, to increase after a meal, to be accom- 
panied with epigastric pain, nausea, and retching, and to be unaf- 
fected by cough medicines and mucilaginous preparations, but to 
yield to acid drinks, emetics, and spontaneous vomiting. A vermin- 
ous cough has been admitted, supposed to be connected with the 
presence of worms in the digestive canal, and which their expulsion 
will alone remedy. Certain diseases of the liver give rise to a cough 
called hepatic. A similar effect has been known to follow certain 
affections of the uterus. Dahaen relates the case of a woman, 
who was, for a long time, affected with continual coughing, and 
who was not relieved of this troublesome symptom, until the spon- 
taneous expulsion of a fibrous tumor from the uterus. 

The moist cough (tussis humida) is that which excites a more 
or less abundant excretion of mucus by the mouth ; in the dry 
cough (tussis sicca) there is no excretion. In most cases, the 
cough occurs but once or twice in succession, then ceasing, to re- 
turn again at a more or less remote period. When the cough is 
both dry and obstinate, the term ferine has been applied to it 
(tussis ferina). In many diseases, it occurs rapidly many times, 
so that a single inspiration is followed by five or six successive 
expirations, constituting paroxysms of coughing (tussis accessus). 
It is, in such cases, accompanied with redness of the face, watery 
eyes, headache, tinnitus aurium, fullness of the cervical veins, 
retching, and sometimes vomiting, as is noticed in pertussis, 
phthisis pulmonalis, and some varieties of bronchial catarrh. 
Finally, the cough, in certain affections, presents a peculiar tone 
and rhythm easily distinguishable, but difficult to describe. Thus 

* The word idiopathic has been generally employed as synonymous with 
essential, and applied to diseases rather than symptoms. But this word being 
evidently the opposite of sympathetic, and it being impossible, in the present 
state of the science, to apply the latter word to a disease, we have thought it 
more proper to apply these two words to symptoms, reserving for disease the 
words essential and symptomatic, these alone being suitable to the present state 
and deficiencies of the science. 



154 SYMPTOMS. 

in the last stage of phthisis, when the lung has become filled with 
numerous and large cavities, the cough has a peculiarly hollow 
sound ; in laryngeal phthisis the cough is low, hoarse, broken and 
rough. In croup, it is said to resemble the bark of the dog, the 
howling of the fox, the crowing of the cock, &c. Nothing precise 
is indicated by these terms of comparison. 

The exploration of the cough by auscultation, furnishes some 
remarkable phenomena. The various kinds of rhonchus are gen- 
erally more marked during coughing than during respiration : thus 
in incipient penumonia and in the same disease when on the de- 
cline, the crepitant rhonchus is often imperceptible, except during 
cough, or the full inspiration which follows it. In phthisical pa- 
tients, if the ear be applied over the ulcerated cavities, a gurgling 
is sometimes distinguished during the cough, which is entirely 
imperceptible in the ordinary movements of respiration. In some 
cases, instead of the gurgling, the fluctuation of a liquid is audible ; 
this sound is similar to that produced by emptying a bottle of the 
liquid it contains. 

Exspuition (expuitio) is the act by which the matters accumu- 
lated in the pharynx are rejected : it is by means of the guttural 
cough, that exspuition is effected. The mucus of the posterior 
part of the nasal fossae, which is carried back into the throat by a 
peculiar inspiratory effort, a sort of snuffing, that of the bronchi, 
which is forced up into the pharynx by the pectoral cough, are 
both rejected in the act of exspuition. 

Expectoration (expectoratio), a term which has been improperly 
applied to the expectorated matter, is the act by which matters 
contained in the trachea, and particularly the bronchi, are expelled 
from them. This occurs in three different ways : 1. When the 
bronchi contain but a moderate quantity of sputa, they are forced 
by the pectoral cough into the pharynx, thence into the mouth, 
and are finally rejected. 2. In cases in which a great quantity of 
liquid is suddenly or rapidly poured into the bronchi, as in certain 
cases of haemoptysis, or the rupture of an aneurismal cyst or 
pleural abscess into the air passages, the expectoration resembles 
vomiting; the lungs, strongly compressed by an almost convulsive 
contraction of the expiratory muscles, transmit this compression 
to the bronchi; the liquid with which they are filled escapes 
through the glottis, and issues in abundance from the mouth, and 
sometimes from the nose: this is a kind of pectoral vomiting; in 
such cases the patient is often said, both by the physician, and 
others, to have vomited blood or pus. In nursing infants and chil- 
dren previous to the fifth or sixth year of age, expectoration rarely 
occurs in any other way. At this age, the sputa are generally 
expelled by pectoral vomiting which follows the efforts to cough : 
in other cases, after being forced into the pharynx by the pectoral 
cough, they are carried by deglutition into the stomach, whence 
they pass into the intestines or are rejected by vomiting, properly 
so called. 3. In other cases, in which the quantity of fluid exhaled 
is small in quantity, it sometimes happens that this liquid rises 



SYMPTOMS. 155 

gradually into the larynx and even the pharynx, without exciting 
any cough, and is expelled by simple exspuition. This mode of 
excretion, which is not uncommon in haemoptysis, it is difficult to 
comprehend, particularly in the vertical position. Some physi- 
cians have supposed, it is true, that, in such cases, the expectora- 
ted matter is secreted in the larynx ; but this supposition, which 
is without confirmation, leaves still unexplained the ascent of 
the blood or mucus. It seems to us, on the contrary, that it 
may be understood by taking into account, 1, the form of the 
air passages, which, being narrow at their termination, become 
gradually larger, to their junction with the trachea ; 2, the com- 
pression which they undergo at each expiratory effort; 3, the 
specific lightness of the mucus, by its admixture with the air ; 4, 
and particularly the difference in the duration of inspiration and 
expiration : the latter being short, the air issues from the air pas- 
sages with more velocity than it enters them, necessarily commu- 
nicating to the matters contained in the bronchi and trachea an 
ascending movement, which more than counteracts that imparted 
to them by inspiration. 

Thus, sometimes, matters, when poured in abundance into the 
bronchi, are carried into the mouth by a single impulsion, as is ob- 
served in certain cases of haemoptysis and emphysema, in which 
the blood and pus are suddenly rejected in great quantity ; they 
are sometimes arrested, as before stated, in the pharynx, and 
afterwards forced by exspuition into the mouth, whence they are 
rejected from the body. 

The act by which the mucus lodged into the mouth or exhaled 
into this cavity is rejected, is called spitting (excr cation). When 
this is often repeated, the phenomenon is termed crachottment ; it 
occurs particularly in gastric derangement, and in cases in which 
the mouth is bitter and pasty, and in nausea. Spitting, exspuition 
and expectoration have this in common, that they may be produced 
by a rapid expiration ; but the cause which produces expectoration 
is below the glottis, that which excites exspuition is above, and 
that of spitting is in the mouth ; in the first case, the obstacle 
which augments the force of the expired air is the glottis, in the 
second, the isthmus of the fauces, and in the third, the lips.* 

Expectoration, exspuition and spitting may be rare or frequent, 
easy or laborious, and sometimes impossible. They are often ac- 
companied with pain, as is observed in peripneumonia, angina and 
inflammation of the tongue. 

The term sputa, is applied to the matters which come from the 
bronchi, trachea, larynx, pharynx, isthmus of the fauces, and the 
posterior part of the nasal fossae or mouth, and which are rejected 
through the opening of this latter cavity, commonly in a liquid 
form, and in small masses at once. These matters are generally 
the result of a morbid secretion of the mucous membrane which 
covers these organs, or of their glands and follicles ; they may 

* The words exspuition and spitting having been vaguely employed by authors, 
we have thought it better to give them a precise signification. 



156 SYMPTOMS. 

also be formed in the substance of these parts or proceed from 
those more remote, having forced a way into their cavity. 

The formation of sputa is not incompatible with health. There 
are many persons, who every day reject a certain quantity, either 
from the mouth or pharynx, or from the trachea or bronchi, 
without being supposed to suffer from disease. 

The sputa present remarkable differences, according to the parts 
from which they proceed. In order correctly to appreciate their 
different qualities and quantity, the physician should require that 
there be a vessel for the exclusive purpose of receiving them. 

Their qualities can be but imperfectly determined when mixed 
with urine, or received upon a cloth which absorbs their more 
fluid portion. 

The sputa formed in the mouth, are more often owing to an 
increased secretion of the mucous membrane, than to that of the 
parotid, submaxillary and sublingual glands. They are com- 
monly clear and almost serous, like the saliva itself; they rarely 
acquire much consistence or opacity, unless in acute diseases of 
the gravest character. They may flow from the mouth, by their 
weight alone ; they may be drawn out without the assistance of 
the organ which contains them ; but they are generally expelled 
by the peculiar act to which the term spitting or sputation has 
been applied. 

The sputa from the isthmus of the fauces and pharynx, are 
generally owing to inflammation of these parts ; they are clear, 
tenacious and ropy, sometimes mixed with small cheese-like lumps, 
which proceed from the follicles of the tonsils, and in certain cases, 
with pus, formed, either in the tissue of these glands, or in the 
substance of the velum pendulum palati, or, what is rare, in the 
parietes of the pharynx, and are rejected by exspuition. 

The sputa which come from the larynx and trachea are gen- 
erally small in size and quantity, and differ but slightly from those 
furnished by the bronchial ramifications in analogous affections. 

The study of the latter (expectorated matters) is of the highest 
importance in all respects ; they are generally the result of a mor- 
bid secretion of the mucous membrane ; but in many cases, they 
proceed from other parts, particularly the parenchyma of the lungs, 
and the pleura ; and sometimes from the neighboring large arteries, 
liver, or the cellular tissue which unites this viscus to the dia- 
phragm. 

The sputa, considered independently of their origin, and in 
regard only to their physical qualities, present numerous varieties, 
which have received distinctive appellations. 

They are called serous, when clear and resembling water ; mucous, 
when of a thicker consistence ; and viscid, when adherent to the 
vessel in which they are contained : this viscidity is sometimes so 
great that the vessel may be turned upside down, without their 
becoming detached, or even, in some cases, their molecules moving 
among themselves. The sputa are called sanguinolent, when 
they consist of a mixture of blood and mucus, as in pneumonia ; 



SYMPTOMS. 157 

bloody, when they contain pure blood, as in haemoptysis. They 
are said to be spotted or streaked with blood, when this liquid 
appears in small masses or in streaks, as in severe bronchitis ; 
frothy, when mixed with bubbles of air, giving them the appear- 
ance of froth ; 'purulent, when they contain pus, and puriform, 
when they only appear to contain it. 

Their color also presents numerous varieties ; they may be 
white, yellowish, rusty, greenish, red, brown, black, or gray ; in 
some cases, transparent, in others opaque, and often, colorless. 
They may also present different shades of color at once. Their 
form is generally rounded when they are easily detached from the 
mouth, and not adherent to its sides ; they are, on the contrary, 
elongated, stringy, or stellated, when viscid ; this latter form is fre- 
quently observed in typhoid fever. They are sometimes firm, dis- 
tinct, and almost hemispherical ; sometimes frothy, flattened, and 
run together so as to form an homogeneous mass. They vary also 
in consistence ; this is, in some cases, aqueous, in others, similar to 
that of a solution of gum arabic, the white of an egg, or even gluey ; 
they are still thicker in some cases of chronic catarrh, in which they 
appear nearly solid. Their odor is generally slight ; it is sometimes 
ammoniacal, fetid and alliaceous like that of the breath, (p. 137.) 
Their taste, in some cases, is sweetish ; in others, saltish, bitter or 
sour ; but the taste generally attributed by patients to the sputa, is 
rather that of the coat which covers the lining membrane of the 
mouth, or the drinks which they take. In some persons, the sputa 
cause a sensation of cold, or heat in the parts over which they pass ; 
but their temperature is generally that of the body. Their volume 
varies in the same persons ; in some, however, they are extremely 
small, or are remarkable for their large size ; in the latter case they 
may .form discs, from one and a half to two inches in diame- 
ter. They vary also in quantity ; being small from some patients 
each day, while others are spitting continually, so as to fill the 
vessel several times in the course of twenty-four hours. It should 
also be remarked that in the same individuals, the sputa may differ 
widely, in all respects, not only in the different periods of the same 
disease, but also in each nycthemerum ; * they are generally more 
abundant, consistent, more opaque and more easily rejected in the 
morning than at other periods of the day. Finally, it is not un- 
common for the same individual to reject, in the course of a few 
minutes, several sputa, differing from each other principally in re- 
gard to their color and consistence. These differences are still 
more marked in patients, who, already affected with a chronic dis- 
ease of the lungs, are attacked with acute inflammation of these 
viscera : in such cases, the sputa resemble those from two different 
patients who make use of the same spit-cup, but are in fact the 
result of two diseases of the same organ, in the same individual. 

To these considerations respecting the various appearances of the 
sputa, we shall add others which are the consequence of the first, 

* JYvl, night; ijutQa, day. 



158 SYMPTOMS. 

and which enable us to determine, from their inspection, the organ 
from which they jiroceed, and the nature of the disease with which 
that organ is affected. 

The manner in which the sputa are rejected often suffices to in- 
dicate their origin ; those that are rejected by simple sputation, or 
which flow out of the mouth, by their own weight, originate in 
this cavity ; those which have been forced by a sort of snuffing, 
or by exspuition, into the mouth, proceed, in the first case, from 
the nasal fossae, in the other, from the larynx or pharynx ; those 
which are carried into the mouth by the pectoral cough {expectora- 
tion), come from the trachea or bronchi, into which they have been 
exhaled or poured, owing to grave alterations of the pulmonary 
parenchyma, pleura, and even more remote organs. It is useful, 
though not always indispensable, for the physician to know the 
manner in which the sputa are rejected, in order to ascertain their 
origin ; their inspection alone suffices for the solution of the double 
problem, under consideration. 

The serous and frothy sputa sometimes originate in the mouth, 
and sometimes in the bronchi. In the first case, if the mouth be 
free from all lesion, they indicate, either an affection of the stom- 
ach, or, in the woman, pregnancy. If the membrane of the mouth 
be of a bright red color, they announce an approaching apthous or 
pseudo-membranous eruption ; if they are owing to mercurial in- 
fluence, the swelling, redness, patches, whitish excoriations, and 
the specific odor of the mouth, would enable us to distinguish them 
from the first. The serous and frothy sputa, the result of expec- 
toration, are observed in pleurisy and incipient bronchial catarrh. 
In the former case, their quantity is very small, in the latter, it may 
be very considerable. 

The mucous sputa generally come from the larynx, pharynx, 
bronchi or nasal fossae. Some patients reject every morning on 
awaking, one or two small, rounded and dried mucous masses ; 
these generally come from the nasal fossae, and are formed during 
the night upon the free border of the velum pendulum palati, 
whence they are forced into the pharynx and rejected. 

The mucous sputa which originate in the pharynx are generally 
viscid, transparent, contain but little air, and are rejected by 
exspuition and with an expression of pain. The mucous sputa 
which come from the larynx are generally smaller in quantity, and 
accompanied with some alteration of the voice. Patients not un- 
frequently cough up sputa, formed by the union of small trans- 
parent globules of a grayish or slate color, which resemble starch 
or tapioca, and whose origin is somewhat obscure. They are 
thought by some physicians to come from the larynx; the numer- 
ous follicles with which the isthmus of the fauces is furnished, 
would lead us to suppose that here might be their origin. 

The mucous sputa secreted in the bronchi are generally of a 
larger size, a rounded form, which they preserve in the vessel, and 
a color varying with the nature and period of the disease. They 
are transparent in recent catarrh ; transparent, viscid and stellated 
in typhoid fever ; and opaque in chronic catarrh. 



SYMPTOMS. 159 

Many persons, in health, every morning reject several sputa, of 
a grayish or blackish color ; this color is owing to the smoke which 
collects from lamps, candles, &c, particularly in small apartments. 

In many diseases, the sputa are purulent ; the product of the 
secretion of the mucous membrane lining the air passages, may 
also in some cases present the appearance of pus which arises from 
ulceration, tubercular softening, or the rupture of an abscess in the 
neighboring parts. The importance of distinguishing between 
purulent sputa and those simply puriform, has been long recog- 
nized, and attempts have been made to find some sign distinctive 
of each. Numerous chemical experiments have been tried; the 
miscroscope has been employed in the examination of mucous and 
pus, but no satisfactory results have as yet been obtained : it is for 
this reason that we have considered the sputa presenting these 
characteristics in connection with each other. 

Pus which escapes suddenly and in abundance from the mouth 
{vomica) always comes from the pleural cavity, and has been 
transmitted into the bronchi by means of a perforation of the pul- 
monary parenchyma, being generally owing to tubercular ulcera- 
tion which has made an opening, either at once or successively 
into the pleura and a bronchial division. The signs of pneumo- 
thorax soon appear, to confirm the diagnosis already established 
from the vomiting of pus, which is sometimes preceded and an- 
nounced by the gurgling mentioned above. When pus or a 
puriform liquid is rejected from the mouth in abundance, (eight or 
ten ounces in the twenty-four hours,) but by successive efforts and 
in small quantities at a time, we may infer that it either proceeds 
from the pleura, as in the preceding case, or from dilated bronchi. 
Auscultation and percussion show to which of these two affections 
these sputa should be referred. 

Pus when rejected pure, but in small quantities, may be owing 
to one of the two preceding diseases, or to one or more tubercular 
cavities. If the sputa be very fetid, they come from dilated 
bronchi or the cavity of the pleura ; if they do not possess this pe- 
culiarity, they may originate in one of these two sources, or a 
tubercular cavity. The progress of the disease and the explora- 
tion of the chest can alone enable us to decide these various points. 

Sputa which contain only streaks or dots of pus commonly mix- 
ed with mucus, and which are rejected by expectoration, may 
proceed from the larynx or lungs. The sensation which precedes 
and excites their expulsion, the alteration of the voice, the small 
size and quantity of the sputa, generally indicate their origin to be 
ulceration of the larynx of a tubercular or syphilitic nature. If 
the expectorated sputa be voluminous and abundant, if they pre- 
sent opaque streaks which are parallel or zigzag in their disposi- 
tion in a mass differing in opacity, and swimming in a clear and 
serous liquid (pituite diffluente), they generally proceed from 
tubercular softening; as the disease progresses, the proportion of 
the clear and serous fluid diminishes, while that of the purulent 
matter increases ; so that in the last period, the sputa no longer 



160 SYMPTOMS. 

contain the clear fluid and are free from strice, presenting the ap- 
pearance of homogeneous pus, but not mixing with water, and 
affecting but slightly, if at all, its transparency. 

There is a disease in which the sputa present so close a resem- 
blance with those of phthisis, that a physician ignorant of this fact, 
would not hesitate, from inspection of the expectorated matters, to 
affirm that they belonged to the latter disease. It is in the rubeola 
of adults, that this peculiarity is noticed. In this case, however, 
the fluid, in which the solid portions of the expectoration float, is 
slightly turbid or opaque, while in phthisis it is always trans- 
parent. 

Pure blood, when it issues from the mouth in abundance, with 
cough, ordinarily comes from the bronchi ; it may, however, also 
come from the nasal fossas, but in this case, if the head of the 
patient be inclined forward, the blood will flow from the nostrils as 
well as the mouth, leaving no doubt as to its source. The blood 
which comes from the bronchi in large quantities may be the re- 
sult of a simple exhalation which, in some cases, replaces some 
other suppressed haemorrhage, but it is generally connected with 
the presence, in the lungs, of tubercles in their crude or softening 
stage, or it may also proceed from the rupture of an aneurismal 
tumor into the air passages. In the latter case, a sudden and fatal 
haemoptysis is sometimes the first sign of arterial lesion. 

Pure blood, when thrown up in moderate quantities, may proceed 
from the same sources, not excepting the latter. We have seen, in 
the case of a porter at the Hospital de la Charite, who presented all 
the signs of an arterial aneurism of the chest, the occurrence of 
moderate haemoptysis which recurred at intervals during the few 
weeks previous to his death. On examining the body after 
death, a perforation of the aneurismal sac and trachea at their 
point of contact was discovered together with such a disposition 
of the fibrinous concretions as to form an incomplete and movable 
partition, which alternately permitted and prevented the escape of 
arterial blood into the trachea. In this case, as in many others, 
the concretions formed an imperfect substitute for the coats of the 
artery, thus retarding the death of the patient. 

Moderate haemoptysis may be also connected with an organic 
lesion of the heart. In all cases, the careful exploration of all the 
circumstances which accompany the haemorrhage is indispensa- 
ble, in order to determine its seat and nature. 

In many cases, the blood is rejected mixed with other liquids, 
as saliva, mucus, and pus. 

Blood which is rejected by sputation comes from the mouth ; it 
sometimes precedes and announces the opening of an abscess of 
the alveoli or tonsils ; it may also arise from suction of the gums, 
a physical lesion of any part of the mouth, and scorbutic swelling 
of the gums: in the latter case, it has a peculiar odor, is clear, 
and of a serous consistence ; it often fills the mouth on awaking, 
and does not flow during the waking state, except on pressure of 
the gums. 



SYMPTOMS. 161 

When blood appears in the sputa in the form of blackish spots, 
it generally proceeds from the nasal fossae ; when in narrow 
streaks, it almost always depends upon the efforts of the patient 
in exspuition or expectoration in cases of angina, catarrhal, pa- 
renchymatous or serous inflammations of the chest. 

Sputa formed by an intimate admixture of blood with mucus, 
are of the highest importance in a semeiological point of view ; 
they may in some cases reveal the existence of an inflammation 
of the pulmonary parenchyma, when there is no pain in the side, 
no considerable difficulty of breathing, nor any phenomena of 
auscultation or percussion to indicate such a lesion. Sputa which 
are viscid, transparent, mixed with small air bubbles, and of a 
red, yellow, or greenish color, clearly, and with certainty, indicate 
the existence of pneumonia ; those which resemble a thick solu- 
tion of gum arabic, are of a red color, and with or without a 
frothy appearance of their surface, are also characteristic of pneu- 
monia, although not very viscid, and often deprived of air ; the 
same is true of serous sputa of a reddish or brownish color {juice 
of the prune or liquorice), which announce a near and almost 
inevitably fatal termination of that disease. The sputa of pneu- 
monia, however, do not constantly present a reddish, yellow, 
or green color ; there are some persons in whom, towards the 
decline, and even during the whole course of this disease, the 
sputa are thick, transparent, and presenting so remarkable a degree 
of viscidity, as to roll about in the spittoon, leaving it almost dry 
and free from stain. 

In some cases, and particularly at an advanced stage of pul- 
monary phthisis, the sputa appear to consist of a mixture of blood 
and pus ; being opaque or of a dull red color, resembling choco- 
late. 

The false membranes which are sometimes thrown out with the 
sputa, may come from various sources. That they occasionally 
proceed from the mouth and throat is evident from simple inspec- 
tion of these parts. The absence of membranous productions in 
the mouth and throat shows that they come from some part of the 
air passages below the epiglottis ; their form and size sometimes 
enable us to determine their source. An alteration of the voice 
generally indicates, in such cases, that they proceed, at least in 
part, from the larynx. 

The sputa sometimes contain hard and concrete matters, having 
a calculous or osseous appearance, as portions of dental tartar, 
small calculi formed in the salivary glands and canals, sequestra 
proceeding from denuded 'and ossified cartilages of the larynx, 
osseous or stony fragments developed in the bronchi, tubercular or 
melanotic products and hydatids. The portions of tartar are 
easily recognized by their peculiar form, and the depression 
they leave in the part of the gum which they occupied ; salivary 
calculi are at once distinguishable by their form and the lesion of 
the organs in which they were developed. A sequestrum formed 
in the larynx generallv produces, before its expulsion, severe 
14* 



162 SYMPTOMS. 

accidents, and particularly violent fits of coughing, sometimes 
threatening suffocation ; the flattened form of these fragments 
assist in their diagnosis. Bony or calculous concretions formed in 
the lungs have almost always a branching form which distin- 
guishes them from all others. Hydatids are easily recognized ; 
they may come from the lungs or liver ; the concomitant signs 
generally enable us to determine in which of these two organs 
they were formed. In regard to the presence of tubercular mat- 
ter in the sputa of phthisical patients, some physicians consider it 
common and easily distinguishable. We are not ourselves of this 
opinion ; during the thirty years in which we have daily and 
carefully examined the sputa of these patients, we have never 
been able to distinguish these pretended melanotic and tubercular 
fragments. 

Lastly, the odor of the sputa furnishes important signs. In 
the mercurial and scorbutic swelling of the gums, and in certain 
syphilitic ulcers of the throat, the excretion exhales the same odor 
as the mouth : a f cecal odor of the sputa generally indicates the 
presence of pus which proceeds from the mouth and isthmus of the 
fauces. The alliaceous odor is peculiar to pus formed in the 
pleura, and rejected through a perforation in the pulmonary pa- 
renchyma. In gangrene of the lungs the odor is not less character- 
istic. A urinous fetor of the sputa should lead us to suspect a 
lesion of the pleura analogous to that described by Dahaen, (a 
renal abscess opening into the bronchi, through the diaphragm 
and ulcerated pleura and lung of the left side.) 



SECTION THIRD. 

Symptoms furnished by the Circulation. 

The circulation which consists in the progressive movement of 
the fluids continually carried from all parts of the body towards the 
heart by means of the veins and lymphatic vessels, and those 
carried from the heart towards the capillary system by means of 
the arteries, is performed, in health, without derangement, and in 
harmony with the organs which concur in its production. Under 
the influence of disease, this function presents numerous derange- 
ments ; some evidently affecting the entire circulation, or at least 
that of the blood ; others being alone appreciable in certain organs, 
as the heart, arteries, or veins. 

The course of the blood may be accelerated through all its 
canals, as is observable in most acute diseases, in which the pul- 
sations of the heart cannot increase in strength and frequency, 
in a given time, without compelling the veins to furnish, and the 
arteries to receive, a corresponding supply of blood. A general 
sluggishness in the movement of the blood is equally appreciable 
under opposite circumstances. 

The force of the circulation may be increased or diminished in 



SYMPTOMS. 163 

all parts of the circulatory system. We daily see persons in whom, 
while the pulsations of the heart and arteries are stronger than in 
health, the veins are harder and more voluminous, and the capil- 
lary system more injected, as is apparent in the increased color 
and marked tumefaction of the integuments; these phenomena 
are particularly remarkable in the affection known as inflamma- 
tory fever. In other diseases, on the contrary, and particularly 
chronic affections without febrile reaction, the impulse of the heart 
is almost imperceptible, the pulse soft, the veins flabby or hardly 
apparent, the skin pale or unequally colored and often covered with 
livid or blueish patches which indicate the languor of the capillary 
circulation. Lastly, in some cases, the course of the blood may 
be momentarily suspended in all parts of the circulatory system, 
as in syncope, in which the pulsations of the heart and arteries 
cease, and the blood no longer flows from orifices made in the 
veins.* 

Notwithstanding the necessary and reciprocal dependence of 
the different parts of the circulatory system upon each other, we 
are led from many facts to admit that each of them, as Laennec 
has observed, has also a peculiar existence, which is more appar- 
ent in the pathological, than in the healthy, condition. It appears 
certain, for example, that the capillary circulation is not entirely 
dependent upon the arterial and venous circulation ; partial con- 
gestions of blood in the capillaries of certain organs, haemorrhages 
which occur in any part without apparent disturbance of the rest 
of the circulatory system, stasis of the blood in the capillaries of 
inflamed parts, all tend to confirm this opinion. The independence 
of the arterial system has not been as generally admitted; it hav- 
ing been shown, however, by auscultation, in certain cases, that 
the arterial pulsations were remarkably strong, while those of the 
heart were extremely feeble, Laennec was led to conclude with 
some other physiologists, that the arteries also have a special 
action, a contractility peculiar to themselves. The action which 
the veins exert in counteracting the influence of gravity and 
temperature, would show that the course of the blood in these, 
is not entirely subordinate to the general circulation. 

We shall now proceed to examine successively the symptoms 
furnished by each of the organs of circulation, the heart, arte- 
ries, capillary system, veins, and the lymphatic vessels and 
glands. 

§ I. Circulation of the Blood. — A. The pulsations of the heart 
may become variously deranged. 

Many of the symptoms of which it is the seat, have claimed 
the attention of physicians of all ages, particularly in the diseases 
which affect this organ itself. The force and feebleness of its pul- 
sations, their regularity, the place and extent in which they are 

* Many persons have been able to suspend for a certain time, by an effort of 
will, the motions of the heart and the arterial pulsations; some have died in 
attempting to repeat this dangerous experiment. 



164 SYMPTOMS. 

felt, have been carefully investigated by observers, and added as 
signs of more or less importance to the history of these different 
lesions. Many practitioners have for a long time been in the habit 
of examining this organ by the immediate application of the ear 
over the region which it occupies ; but it is to the work of 
Laennec that we are indebted for the accurate knowledge and 
appreciation of this, as also many other pathological phenomena. 

The pulsations of the heart should be examined with reference 
to the four following points,, viz : the extent and place in which 
they are audible, the stroke or the force of the impulse of the 
organ, the nature and intensity of the sound, and finally, the 
rhythm according to which these different parts contract. 

1. In a healthy man, and in the adult age, the pulsations of the 
heart are only audible in the space comprised between the cartila- 
ges of the fifth and seven true ribs, and in the corresponding 
points of the sternum. The pulsations of the left cavities are 
principally felt in the first, and those of the right in the second 
point. This space in which the motions of the heart are percep- 
tible is much more limited in very fat subjects, and those who 
have been subjected to repose and diet ; it is greater in lean indi- 
viduals, whose chests are narrow, in children after exercise or 
meals, or under the influence of a lively emotion. In these cases, 
the pulsations may be perceptible over the greater part, or even 
the whole of the left side. When under the influence of disease, 
the pulsations of the heart are audible over a greater extent than 
in health ; they become progressively perceptible, 1, in the left 
side of the chest, from the arm-pit to the region of the stomach ; 
2, in the same region of the right side ; 3, in the posterior 
part of the left chest ; 4, in the posterior right chest. When 
perceptible over a greater extent in disease, they depend upon 
a lesion of the heart itself, and, according to some authors, 
to lesions of the neighboring parts. Laennec thought that in- 
duration of the pulmonary tissue, effusion of serum into the 
pleura, and the presence of tubercular cavities, might occasion 
this phenomenon ; but generally, in these cases, the difference is 
not well marked and often doubtful : it is particularly in the 
heart itself that are found the causes which increase the extent 
over which its pulsations are felt. It was the opinion of Laennec 
that this extent was in direct ratio with the feebleness and thin- 
ness of the parietes of the heart ; that the size of the heart does 
not affect the extent over which the pulsations are perceptible, 
unless accompanied with enlargement of its cavities. The trans- 
mission of the sounds of the heart appear to us also to depend 
upon certain conditions presented by the chest, and which render 
it more fitted to conduct the sounds produced within its cavity. 
There are some individuals in whom, when in a state of complete 
physical and moral quiet, the pulsations of the heart are trans- 
mitted to almost all parts of the chest, although presenting in the 
precordial region no more than their ordinary force, and unaccom- 
panied by any signs of disease, either of the heart or other tho- 
racic organs. 



SYMPTOMS. 165 

The space, in which the pulsations of the heart are audible, may- 
become diminished ; this is observed in rare cases of atrophy of 
this organ. 

The cardiac pulsations may be perceptible in a place differing 
from that where they ordinarily appear. This phenomenon may 
be owing to a general transposition of the viscera ; such cases are 
congenital, and present nothing morbid. But generally, when the 
pulsations are perceptible above or below, to the right or left of the 
place where they are ordinarily felt, the phenomenon is owing to 
some pathological condition. The presence of a tumor or the ac- 
cumulation of fluid in one side of the chest, in the mediastinum or 
abdomen, are the more common causes of this displacement. In 
some cases, the pulsations differ in their place of appearance at 
different times ; this phenomenon which authors have considered 
as peculiar to hydropericardium, is very rare, and difficult to 
detect. 

2. The beating or impulse is a sensation of percussion conveyed 
to the ear, or hand of the observer, by the cardiac pulsations. 

When the conformation of the heart is in perfect harmony with 
that of other parts, this impulse is almost imperceptible ; often 
entirely so ; it increases under the influence of the causes which 
hasten the pulsations of this viscus, and becomes again natural 
when these cease to act. 

In hypertrophy of the heart this impulse generally becomes 
stronger as the thickness of the parietes of this viscus is increased ; 
and is sometimes carried to such a degree as to heave the head of 
the observer ; the greater the hypertrophy, the more slowly this 
heaving takes place. There are, however, numerous exceptions to 
this ; for it is not uncommon to meet with patients in whom the 
heart has acquired an enormous size, from thickening of its walls 
and dilatation of its cavities, without any corresponding increase 
in the force of the impulse ; it is even sometimes feebler than in 
the normal condition. 

The impulse is produced at the moment of ventricular contrac- 
tion. Hypertrophy of the auricles may, however, also give to the 
ear or hand a very perceptible impulse ; but this is deeper and 
more feeble than that which depends upon ventricular contraction. 
In health, there is never but one impulse to each systole of the 
heart ; in some diseases of this viscus, succeeding the first impulse 
which corresponds to the contraction of the ventricles, two others, 
isochronous with their dilatation, have been observed. M. M. 
Andral * and Bouillaudf each cite a case of this kind. We have 
also had occasion in several instances to observe this phenomenon, 
without being able to find by comparison of the symptoms and 
anatomical lesions, a satisfactory explanation of this triple impulse. 

The impulse is ordinarily confined to the precordial region; it 
sometimes extends to the neighboring portion of the sternum and 

* Notes a la quatrieme edition de Laennec, t. iii. p. 26. 
f Traits cliniuue des Maladies du Coeur, t. 1, p. 148. 



166 SYMPTOMS. 

epigastrium, rarely beyond, unless the heart be both thickened and 
dilated. 

The absence of impulse, like that of sound, in the precordial 
region depends, either upon a natural feebleness in the contractions 
of the heart, or rather upon the position of this viscus, it being situat- 
ed deep in the mediastinum, and entirely covered by the lungs, an 
anatomical disposition not unfrequently occurring, and which is 
sometimes produced by pulmonary emphysema. The impulse of 
the heart is also wanting in cases of considerable effusion of liquid 
into the cavity of the pericardium. 

3. Nature and intensity of the sound. If the ear or stethoscope 
be applied to the region of the heart in a healthy person, two suc- 
cessive, and different, sounds are heard ; the first, is dull and pro- 
longed, coincides with the vertricular systole and is isochronous 
with the pulse. Succeeding this, is another, which is clearer and 
smarter, being analogous to the sound produced by the flapping of 
a bellows' valve, and occurring during the diastole of the ventri- 
cles. Many theories have of late years been proposed by physi- 
cians and physiologists, in order to explain the mechanism and 
cause of these two sounds. They have, by some, been referred to 
the contraction of the auricles and ventricles, by others, to the im- 
pulse of the blood against the parietes of the heart and great vessels ; 
others have attributed them to the collision of the particles of this 
fluid with each other, and again others to the successive impulse 
of the point and base of the heart against the anterior parietes 
of the chest ; but the theory of Roannet, which refers the sounds 
of the heart to the action of the valves is that which at present is 
most generally admitted. According to this physician, the first 
sound is produced by the closure of the mitral and tricuspid 
valves ; the second, by the sudden closure of the sigmoid valves of 
the aorta and pulmonary artery. This theory is favored by the 
greater number of pathological facts ; there are however many 
abnormal sounds of the heart, which cannot be explained by this, 
or any other yet proposed.* 

In health, the two sounds of the heart have each a peculiar 
character, which, in disease, may become variously modified. At 
one time, the sounds become duller or more clear; at another, 
they are replaced by others which have received various names. 
It is exceedingly rare for the both sounds to be altered at the same 

* From the highly interesting and conclusive experiments of Drs. Pennock and 
Moore, of Philadelphia, and the committees of the British Association, it would 
appear that the first sound of the heart is probably caused by a combination of that 
caused by the contraction of the auricles, the flapping of the auriculo-ventricular 
valves, the rush of blood from the ventricles, and the sound of muscular contrac- 
tion. But it is to the latter that it appeared mainly attributable, its dull sound and 
prolonged duration being owing to the progressive character of the full systolic 
effort from fundus to apex. 

The second sound, according to these experiments, is caused exclusively by the 
closure of the semilunar valves, from the reaction of the arterial columns of blood 
upon them. The cause of the second sound corresponds nearly with Roannet's 
theory. — Trans. 



SYMPTOMS. 1G7 

time ; in most cases, one alone presents modifications in its tone, 
nature or duration. 

The sounds of the heart are dull and stifled, in cases of consid- 
erable hypertrophy, thickening of its valves, or when the free play 
of the latter has been obstructed by the formation of concretions 
upon their surface. In those cases, they are sometimes dry and 
hard, a modification to which M. Bouillaud has applied the term 
bruit de parchemin * or parchment sound. 

Increased clearness of the sounds is a very rare phenomenon ; it 
is however observed in dilatation with attenuation of the parietes 
of the heart. 

It frequently happens that the sounds of the heart are replaced 
or masked by a bellows murmur, so called from its exact resem- 
blance to the sound of that instrument. This murmur is loud or 
feeble, sometimes just perceptible, and sometimes confined to a 
limited space, or extending over the whole precordial region ; in the 
latter case, there is generally some point in which it presents its 
maximum intensity, a circumstance which may be of importance 
in the diagnosis of the disease. In some very rare cases, both the 
normal sounds of the heart are masked or replaced by this mur- 
mur, which may lead us to supect, either the simultaneous altera- 
tion of both orifices, the arterial and auriculo ventricular, or a 
twofold alteration in one of those orifices, causing its contraction, 
and inefficiency of its valves. 

The bellows sound whatever be its degree of intensity, is not 
pathognomonic of any particular disease of the heart, for while, on 
the one hand, it may exist in nearly all the affections of this viscus, 
on the other, it fails in some of the most severe, and particularly 
in contractions of its orifices. The bellows sound may exist in 
simple pericarditis, hypertrophy, and particularly that form called 
concentric hypertrophy. But it is most often found in fibrous, car- 
tilaginous or cretaceous contractions of the orifices, and inefficiency 
of the valves. It also frequently exists in cases in which the ac- 
tion is increased without any material lesion of its tissue, as in 
nervous palpitations. Finally, it may be heard in plethoric indi- 
viduals, pregnant women,f but particularly in anemic persons, in 
young girls affected with chlorosis, and after abundant haemor- 
rhages, as has been shown by the observations and experiments of 
Dr. Marshall Hall, of London.^; 

It follows from these facts, that the bellows murmur may be de- 
veloped in various and even opposite conditions : how uncertain 
then are all those explanations in which this sound is attributed to 
a single mechanism. 

Many other sounds have been revealed by auscultation, which 
Laennec has justly considered but varieties of the bellows sound, 
and which have been designated by the terms, filing {bruit de 
lime), rasping {bruit de rape), sawing {bruit de scie), and musical 

* Traiti des Maladies du Coeur, t. 1, p. 162. 

f Vide a good thesis by M. Jacquemier Paris, 1837, No. 366. 

j Med. chirurg. trans, t. xvii. 



168 SYMPTOMS. 

or whistling sounds. The rasping or filing sound gives to the ear 
a sensation of harshness or roughness, which has been compared 
to the sound produced by filing wood. If, in these cases, the hand 
be applied to the precordial region, a peculiar vibration is felt 
called the purring tremor (premissement cataire), first pointed out 
by Corvisart, and which Laennec compared to the purring of cats. 
The sawing sound closely resembles the sound of the saw, when 
heard at a little distance. It has also been compared by M. Bouil- 
laud to the sound of the letter S, when prolonged. The whistling 
or musical sound which Laennec never distinguished except in the 
arteries, we have several times observed in the heart itself; in one 
case it was so intense as to be heard at the distance of several feet. 

The rasping, filing and sawing sounds and the purring tremor 
are most commonly heard in contraction of the orifices, particularly 
if the valves present cretaceous, rough or unequal indurations. 
We have, however, several times observed the rasping sound in 
cases of anemia, and after abundant bleeding. The same phe- 
nomenon has been noticed under similar circumstances of Dr. 
Marshall Hall. 

The musical or whistling murmur of the heart has not been con- 
nected with any distinct lesion of this viscus ; in the two cases 
which had presented this phenomenon and in which an autopsy 
was made, the existence of hypertrophy with dilatation of the 
left cavities was discovered, without lesion of the orifices. 

We shall close the history of the anormal sounds of the heart, 
by briefly noticing the bruit argentine or silvery sowid, pointed 
out by Laennec, and the semeiological value of which is not yet 
determined. It may be imitated, says M. Filhos, by placing the 
pulp of the middle finger just within the meatus externus, so as 
completely to close it, and at the same time tapping it lightly with 
the other hand.f Most authors have considered this sound as 
peculiar to hypertrophy, occurring when the contractions of the 
heart have become very powerful. Laennec supposed it to be 
exclusively owing to the presence of air bubbles within the 
pericardium, together with hypertrophy of the heart ; but this 
opinion has not yet been verified by autopsies. M. Bouillaud 
attributed the same phenomenon to the stroke of the heart against 
the thoracic parietes. He thought that the silvery sound which is 
always produced during the ventricular systole, was only a sound 
superadded, and which does not render the two normal sounds 
inaudible. 

If, in the healthy condition, the gliding of the heart within the 
pericardium be unaccompanied by any appreciable sound, this is 
no longer the case after the formation of false membranes upon 
the serous envelope of the heart, which destroy its smoothness, 
and which are the result of inflammation. Thus abnormal sounds 
may be produced in the pericardium, as in the pleura, and under 

* This is the metallic tinkling of Bouillaud, or the auriculo-metallic sound of 
M. Filhos. 
t Theses de Paris, 1833, No. 132, p. 14. 



SYMPTOMS. 169 

the same conditions. These sounds were observed by Laennec, 
but he did not attach to them due importance. He speaks of a 
sound of leather, which he at first thought depended upon pericar- 
ditis, but which he afterwards confounded with the metallic tink- 
ling, attributing it to the presence of air bubbles in the pericar- 
dium.* M. Collin was the first to give a correct description of 
this phenomenon, and point out its semeiological value by con- 
necting it with the existence of false membranes, and thus con- 
stituting it one of the pathognomonic signs of pericarditis. This 
sound presents various degrees of intensity; to the feeblest of 
these, M. Bouillaud proposed to apply the term grazing (frole- 
ment) ; he compared this sound to that produced by the rumpling 
of taffeta, parchment, or a bank note between the fingers ; this 
sound which is very superficial, is heard during the systole and 
diastole, but is more marked during the former, f The sound of 
new leather (cuir-neuf), investigated by M. Collin, resembles 
that produced by a horseman on a new saddle. This sound is 
observed under the same circumstances as the preceding ; but it 
seems to depend on false membranes, which are harder and more 
resistant. Lastly, when the false membranes have become fibro- 
cartilaginous, a much ruder sound is produced, for which M. Bouil- 
laud has proposed the term scraping sound {bruit de raclement).% 
These different sounds are often important in the diagnosis of peri- 
carditis. 

4. The term rhythm, Laennec applied to the order of succession 
in the contractions of the different parts of the heart, and to 
their respective and relative duration. In health, the first or dull 
sound which coincides with the ventricular systole is nearly iso- 
chronous with the pulsation of the radial artery. Succeeding 
this, is the second or flapping sound, between which and the first, 
according to M. Marc d'Espine, there is a very short interval of 
silence, during which, with great attention, the arterial pulsation 
can be distinguished. To this succeeds a brief, but well marked, 
period of repose, after which the ventricles again contract with 
the dull sound and the gradual progression peculiar to them. The 
contraction of the ventricles, the flapping sound and the pause 
which succeeds, are not of equal duration. The duration of the 
first sound is almost double that of the second, the latter being 
about equal to the interval of repose, and sometimes a little less. 

This succession in the motions and sounds of the heart is best 
distinguished when the pulsations of this organ are fewest in a 
given time ; indeed, when the number of the arterial pulsations 
becomes much increased, the ear can no longer clearly distinguish 
the period of silence to which we have just alluded. 

In disease, the duration of each sound may become modified ; 
thus, in some cases of hypertrophy, the first sound is so prolonged 
as sometimes to mask the flapping sound, at the same time short- 

* T. 3, p. 5, 4th edition. 

f Traiti Clinique des Maladies du Coeur, t. 1, p 457. 
X L. c. p. 198. 
15 



170 . SYMPTOMS. 

erring the period of silence, and rendering it almost imperceptible. 
A loud and continuous bellows murmur is also not unfrequently 
heard in the precordial region, which replaces or entirely masks both 
the normal sounds, together with the interval of silence. We have 
previously referred to those cases in which the rhythm of the car- 
diac pulsations is so perverted, that following a single ventricu- 
lar systole, two, three, or four other impulses coincident with the 
diastole are distinguished. Finally, the natural rhythm of the 
heart may be perverted by intermittences, irregularities, or ine- 
qualities in its pulsation : the latter may be accelerated or retarded, 
all which phenomena will be considered in connection with the 
pulse. 

The symptoms furnished by auscultation of the heart should 
never be separated from those which are the results of percussion. 
In the healthy condition, percussion over the precordial region gives 
an obscure sound over an extent not exceeding two inches square. 
This space increases, and its sound becomes duller, owing to 
increased size of the heart, or a liquid effusion into the pericardium. 
In a treatise published in 1826, M. Louis proclaimed the impor- 
tance of the signs furnished by percussion of the precordial region 
in the diagnosis of pericarditis ; he proved that the more or less 
rapid increase in the extent over which a dull sound is obtained, 
is the most certain sign of liquid effusion and, consequently, peri- 
carditis ; for an effusion confined to the pericardium is an almost 
constant sign of inflammation ; hydropericardium without inflam- 
mation rarely occurs except in cases of general dropsy. 

B. The term pulse {pulsus) is applied to the beating of the 
arteries produced by the afflux of blood propelled by the heart at 
each contraction. 

Galen was the first to call the attention of physicians to this 
phenomenon. Those who preceded him have hardly alluded to 
it, and seem to have overlooked it. 

The pulse, in health, is equal, regular, supple, and moderate in 
strength. The number of the pulsations varies with the age, 
temperament, sex, stature, idiosyncrasy and other accidental cir- 
cumstances. It has been for a long time supposed that the num- 
ber of arterial pulsations, during the first months of life, were 
about one hundred and forty per minute ; at the second year, one 
hundred ; at puberty, eighty ; from sixty-five to seventy-five in 
adults, and from fifty to sixty in old age. But it would appear 
from works recently published that this estimation of the fre- 
quency of the pulse, in the different periods of life, is incorrect. 
Billard asserts that the frequency of the pulse in the new born 
infant is often no greater than in the adult, and in forty infants 
from one to ten days' old, he found eighteen in whom the pulse 
was less than eighty in the minute* Dr. Valleix indicates the 
number eighty-seven, as the medium of the frequency of the 

* Mai. des Enf.,p. 67. 



SYMPTOMS. 1 71 

pulse in infants aged from two to twenty-one days.* Finally, 
M. M. Leuret and Mitivie, by studying the comparative frequency 
of the pulse in a great number of persons, both old and young, 
have shown it to be greater in the former than in the latter, since 
the mean, in the aged, was seventy-three, and, in the youth, 
sixty-five, f It would be desirable that the researches upon the 
frequency of the pulse during the first periods of life, be made 
upon other than hospital patients, as these are badly nourished, 
and not in the ordinary healthy conditions. It is also necessary 
that the results should be deduced from a great number of facts. 
The frequency is a little greater in women, in individuals of a 
sanguine or nervous temperament, and, it is said, in those of small 
stature. It has been shown, by repeated observations, that the 
proportion of adult subjects in whom the number of arterial pul- 
sations is below sixty, and even fifty per minute, is greater than 
is generally supposed. There are many persons in whom the 
pulse is not over thirty-six or forty, in others, it has been observed 
as high as one hundred per minute. Whitt saw a woman whose 
pulse, in health, beat one hundred and twenty per minute. 

Beside these individual varieties, the number of pulsations be- 
comes increased after a meal, by exercise, emotions, and during 
pregnancy; it is diminished in the sitting or horizontal posture, J 
by repose, diet, loss of blood, and particularly the use of digitalis ; 
it is not rare however for the pulse to become accelerated after 
abundant haemorrhages, and all excessive evacuations. In some 
persons, the frequency of the pulse during convalescence is less 
than in health. It has been said that the pulse presents, at dif- 
ferent hours of the day and night, slight modifications, which, 
according to the assertions of Brian Robinson, coincide with those 
of the barometer and thermometer. But these observations, sup- 
posing them to be correct, are unimportant, as offering no useful 
application. The pulse also presents varieties in different individ- 
uals, in regard to the force, regularity and equality of its pulsa- 
tions ; it is highly important for the physician to be acquainted 
with the normal condition of the circulation of persons to whom 
he is called in sickness ; this knowledge is always useful, and often 
indispensable in order to appreciate the changes effected in the va- 
rious circulatory phenomena, and particularly the pulse, through 
the influence of disease. 

I have seen a lady whose pulse, during the paroxysms of inter- 
mittent fever, did not beat above sixty per minute, to the great 
astonishment of her physician. This astonishment would have 
ceased had he counted the number of pulsations during the inter- 
mission, these being not above forty per minute. 

There are many precepts which should not be neglected in the 
mode of feeling the pulse. 

* Clin., des Mai. des Enf., p. 18. 

■{■ De la Frequence du pouls. 

f Guy's Hospital Reports, April, 1836. 



172 SYMPTOMS. 

The physician should wait till the patient shall have recovered 
from the emotion produced by his presence, requesting him to pre- 
serve absolute silence and to remain in the sitting or horizontal 
posture. The pulse may be examined at the temples, lateral parts 
of the neck, arm, thigh, wrist, and wherever the arteries are suffi- 
ciently large and superficial ; but the radial artery is generally 
preferred, at the place where it ceases to be covered by the muscles 
of the fore arm, opposite the radio-carpal articulation. 

If the patient be up, he should be placed in the sitting posture ; 
if in bed, he should be upon his back, so that he may neither in- 
cline to the right or left, and thus impede the circulation of blood 
in the arteries. The arm should be placed nearly in a state of ex- 
tension and sustained in its whole length, so that the muscles may 
be relaxed. The fore arm should be nearly prone that it may rest 
upon the cubital edge, and the radial edge be a little raised. Care 
should be taken that no bandage or clothing impede the flow of 
blood in the axillee, at the elbow or any other point. All bandages 
should be removed so that there be the least possible compression. 
By means of these various precautions, we may be certain that 
there is no foreign obstacle to the flow of blood through this vessel. 

The artery of the left side should be felt by the right hand, and 
vice versa ; the four fingers placed parallel on the same line should 
be applied over the track of this vessel ; the index finger should be 
nearest the hand of the patient ; and the little finger, applied 
lightly, should be the first to receive the impulse of the blood ; at 
the same time that the four fingers are placed over the radial 
artery, the thumb, or rather the palm of the hand should rest upon 
the dorsal face of the fore arm, thus affording a solid support to 
the fingers by which the pulse is examined. The latter should at 
first receive a slight lateral movement, in order to ascertain the sit- 
uation of the vessel. When the fingers are all placed upon the 
artery, the pressure should be gradually increased and diminished 
several times in succession, so as to appreciate the influence of the 
pressure upon it, and thus more easily ascertain its different quali- 
ties. Twenty or thirty successive pulsations should, in this man- 
ner be examined. It is not without advantage to examine the 
pulse in the two arms alternately, or at once ; it should also, in 
particular cases, be examined in other places, wherever it may 
throw light upon the diagnosis. It may be also examined several 
times, or at least a second time, before leaving the patient. How- 
ever minute these precepts may appear, they cannot be neglected 
without inconvenience. It is better to accustom oneself from the 
beginning to this mode of examining the pulse ; it may be then done 
without effort, and by the simple effect of habit. 

The changes effected by the influence of disease upon the arte- 
rial pulsations are twofold ; those which are appreciable at each 
beat ; and those only perceptible by the comparison of a certain 
number with each other. To the first series belong quickness and 
slowness, hardness and softness, fullness and smallness, feebleness 
and strength ; to the second, frequency and rareness, irregularity 



SYMPTOMS. 173 

and inequality ; these different conditions of the pulse will be suc- 
cessively considered. 

a - The pulse is quick {pulsus celer), when the arterial pulsation 
takes place with quickness ; slow (pulsus tardus), on the contrary, 
when it is performed more slowly than in health. 

Hardtiess and softness of the pulse are characterized by the 
greater or less degree of tension of the artery during its pulsation. 
If the beat gives the finger the impression of a hard body striking 
against it, the pulse is hard (P. durus) ; it is soft (P. mollis) when 
it gently strikes the finger, and is easily compressible. The cordy, 
tense and resisting pulse are but varieties of the hard pulse. It 
would not be impossible, in old persons, to confound, with hardness 
of the pulse, the resistance which depends solely upon ossification 
of the arteries. The latter is easily recognizable from the firmness 
of the parietes in the interval, and their annular disposition. 

Fullness and smallness of the pulse are measured by the volume 
which the artery presents in pulsating: the pulse is full (P. mag- 
nus) when the artery is large and full ; it is small (P. exilis) when 
the pulsations of the artery are slender and weak. The full, devel- 
oped, and great, are but varieties of the large, pulse ; the contracted 
pulse is that which is at the same time small and hard. 

The strong pulse is characterized by its volume and the force of 
the pulsations ; the feeble pulse by the opposite qualities. Strength 
of pulse (P. robur) consists consequently in hardness and great- 
ness united; feebleness (P. debilitas), in the smallness and softness 
of the pulsations. The vibrating pulse, occurring in cardiac aneu- 
rism, is a very strong pulse; the depressed pulse, of diseases which 
tend to a fatal termination, is a very feeble pulse. 

Thus slowness and quickness, softness and hardness, smallness 
and fullness, are the principal qualities of the pulse, which, by 
their different degrees and combinations, constitute the varieties 
appreciable in each pulsation. 

There are two other varieties which are sometimes confounded, 
but ordinarily very distinct ; we refer to the trembling pulse and 
the pulsus dicrotus. In both these cases the arterial pulsation is 
not single ; it gives in the latter case the sensation of a double 
beat, which has been compared to the rebounding of the hammer 
on the anvil. In the first, the pulsation is, as it were, uncertain 
or hesitating ; the fingers placed upon the artery distinguish at 
each contraction of the heart a trembling pulsation, instead of a 
single beat. It is not very uncommon to meet with persons in 
whom it is difficult to determine whether the pulse be redoubled 
or trembling. 

/*• The frequency and rareness of the pulse are measured by the 
number of arterial pulsations in a given time. The pulse is fre- 
quent (P. frequens) when this is greater than in health ; when it is 
less, the pulse is infrequent (P. rarus) (p. 170). Of all the qualities 
of the pulse, frequency is alone that which can be measured with 
rigorous precision by means of the watch. This mode of estimat- 
ing the frequency of the pulse is very useful to the beginner, 
15* 



174 SYMPTOMS. 

who becomes thus accustomed to value it with precision ; but it 
becomes unnecessary to the experienced physician, who only has 
recourse to it in those affections, in which it is important to note 
the slightest alterations in the number of the arterial pulsations 
from day to day. It has been recommended by some physicians 
to count the pulse during a whole minute ; but a half minute ordi- 
narily suffices, or, what is better, two quarters, the one serving to 
correct the other. If the frequency of the pulse be extreme, it will 
be found necessary to count the number of pulsations occurring in 
five seconds, several times in succession, since the cyphers which 
represent the low numbers are nearly all monosyllables, and may 
be pronounced as rapidly as the most frequent pulse, which is not 
the case with the higher numbers. I have been able, in this way. 
to count accurately one hundred and sixty, one hundred and eighty, 
and even two hundred pulsations in the minute ; while in attempt- 
ing to count an entire minute, or even a half minute, it would be 
found impossible to count above one hundred and fifty. Fre- 
quency of the pulse is much more common in disease than its in- 
frequency, the latter rarely occurring except in certain periods of 
some cerebral affections, in concussion of the brain, and in certain 
organic lesions of the heart. We recollect a young man at La 
Charite, suffering from the latter disease, whose pulse did not ex- 
ceed twenty-eight, and sometimes not even twenty-five pulsations 
per minute. Finally, we saw with Dr. Meniere, a patient in 
whom the number of the arterial pulsations was not above fourteen 
per minute, this infrequency lasting for about twelve hours. Fre- 
quency of the pulse, on the contrary, occurs in nearly all acute 
diseases and in a great number of chronic affections. It is almost 
always accompanied by quickness; sometimes, but rarely, the 
pulse is frequent without being quick, or quick and at the same 
time rare ; when the pulse beats more than eighty times per min- 
ute, it is very difficult to judge of its quickness; this is entirely 
impossible if the pulsations exceed one hundred and twenty, or 
even one hundred. 

The constant relation which exists, in health, between the fre- 
quency of the respiration and that of the pulse, is also generally 
apparent in disease, being in the proportion of four to one. We 
are assured by Giannini that we can thus by examination of the 
respiration alone, and without touching the patient, determine the 
frequency of the pulse in all diseases. This assertion may be gen- 
erally correct, so far as it relates to other than thoracic affections ; 
but it presents numerous exceptions, particularly in nervous dis- 
eases, in which this relation between the circulation and respiration 
is often deranged. 

The pulse is regular (P. regularis) when the pulsations succeed 
each other at equal intervals ; it is irregular (P. irregularis), 
when the pulsations return at unequal intervals. The pulse pre- 
serves its regularity in most mild acute diseases ; in persons whose 
pulse is naturally irregular, the arterial pulsations may become 
regular under the influence of disease. Dehaen observed two 



SYMPTOMS. 175 

cases of this kind, noticing with anxiety the irregularity which 
appeared towards the period of convalescence ; but the patients 
themselves, who were aware of the peculiarity of their natural 
pulse, viewed it as a favorable sign. Irregularity of the pulse 
may present itself under various forms ; sometimes one of the 
pulsations appears to fail completely, this is the intermittent pulse 
(P. intermittens) ; sometimes, but more rarely, a pulsation occurs 
in the interval between two regular pulsations ; this is called an 
intercurrent pulse (P. intercidens). bitermmittence and intercur- 
rence may occur at equal intervals; but the periodicity rarely lasts 
more than a few minutes, or at most, a few hours. They are or- 
dinarily symptomatic of an organic lesion of the heart ; they may 
appear in neuroses, and in some cases have appeared to be con- 
nected with the presence of worms, or the accumulation of gas in 
the intestinal canal, and the acute abdominal pain which occurs in 
some intestinal phlegmasia? ; they appear in the last few hours of 
life in most diseases, and finally, are not unaffected by cerebral 
influence. A professor of medicine at Bologna, having accidentally 
remarked an intermittence in his own pulse, became in conse- 
quence very anxious ; he was constantly placing his fingers upon 
the artery, and observed at each time that the pulse became more 
irregular ; Morgagni, whom he consulted upon the case, advised 
him to pay no attention to it, and the intermittence soon disap- 
peared.* 

Laennec was led, from auscultation, to admit false intermis- 
sions ; in these, the contraction still takes place, but in so rapid 
and feeble a manner, that no pulsation is felt in the artery ; in 
such cases, there is intermittence of the pulse, and simply inequal- 
ity in the contractions of the heart. 

During intermission of the pulse, the artery is almost always 
soft and unresisting. Some physicians appear to have observed 
cases in which the artery was full and tense; Laennec supposed 
that this kind of intermittence takes place after ventricular con- 
traction, and that while it lasts there is probably a permanent con- 
traction of these organs. 

The equal pulse (P. cequalis), is that in which the pulsations 
resemble each other in quickness, fullness, and hardness. The 
pulse is unequal (P. inequalis), when the pulsations differ from 
each other in these respects. 

The sense that we have attached to the words unequal and 
irregular, differs from that given to them by most authors, who 
have employed these two expressions indifferently. We have 
thought it better to give to each a precise signification, as was the 
case in regard to respiration ; we have applied the word regularity 
to the rhythm, and inequality to the other qualities of the pulse. 

The pulse may cease to be distinct or become confused, from 
extreme frequency, but particularly the feebleness, irregularity, and 
inequality of the pulsations. There is no degree of frequency in 

* De sed. et Caus. morb.. Epist. xxiv., art. 20. 



1 76 SYMPTOMS. 

which the pulse may not be counted, bat, generally, as its frequency 
increases, it becomes more feeble, irregular, and unequal, so that it 
is impossible to determine with accuracy the number of pulsations 
per minute. In this, and in many other cases in which this de- 
rangement does not exist to such a degree, an approximate evalu- 
ation is alone practicable. The pulse may become insensible 
(pulsuum defectio), like that which occurs in the moribund, and 
sometimes after excessive evacuations in persons who are not 
otherwise seriously indisposed. 

Is the pulse the same, or does it present remarkable differences, 
in the various arteries in which it may be examined ? This 
question comprises many others which will be successively consid- 
ered. 

The fullness and hardness of the pulse vary with the size of the 
artery examined ; the larger the artery, the stronger is the pulse. 
Thus in cases in which the arterial pulsations become insensible 
at the wrist, they are manifest at the bend of the arm, and full and 
hard in the groins. For the same reason, it may, and frequently 
does, happen, that the strength of the pulsations differs in the same 
subject in two corresponding vessels, the two radial arteries, for 
example. This difference depends upon the unequal size of this 
artery in the two arms, or the variable depth at which it is seated. 

Many physicians have, from certain cases, been led to suppose 
that, in some cases of congestions, and in certain neurosis, the 
pulsations in the arteries which are distributed to the affected 
organ, are stronger than in those of the rest of the body. In 
most cases, there is supposed to be increased strength in pulsations 
of such an artery, as the superficial temporal, the strength of 
which in the healthy condition is not appreciated, and which, in 
disease, is generally estimated rather from the evidence of the pa- 
tient than that of the senses of the physician ; now, the sensation 
experienced by the patient may depend upon increased sensibility 
of the parts surrounding the vessels, as well as the often doubtful 
increase in the strength of the arterial pulsations. 

Do the differences presented in the force of the arterial pulsa- 
tions in different parts of the body, exist in their quickness, fre- 
quency, regularity, or equality? 

It is difficult to conceive how the quickness can vary in the 
different arteries ; as, however, there is a difference in the con- 
tractility of the various parts of the arterial system, it might not 
be impossible for the quickness with which the pulsation is 
effected, to differ slightly in one artery from that of another ; but 
this phenomenon, if it exist, would be difficult to appreciate. The 
greater frequency of the pulse in an artery, which some authors 
pretend to have observed, cannot be admitted ; in certain local 
congestions, the pulse may seem to the patient to beat oftener in 
the inflamed part than elsewhere ; but from a knowledge of the 
laws of the circulation, we cannot admit the existence of any 
other pulse in the arteries, than that dependent upon the afflux of 
blood propelled by the contraction of the heart ; now, as the whole 



SYMPTOMS. 177 

arterial system has a common origin in this organ, it is evidently 
impossible for the pulsations to be more frequent in one artery 
than another. 

It has, however, sometimes happened, that the number of pul- 
sations in a given time was not the same in the two sides ; a very 
remarkable case is related by Morgagni. A child who received 
an injury in the back by a fall from a tree, was attacked with pal- 
pitation, which had not disappeared after a lapse of nine years, 
and which became particularly troublesome at certain periods of 
the year. Morgagni having seen this patient in one of these 
paroxysms, found upon examination a difference in the pulse of 
the two sides: "after a careful examination, he found that the 
arterial pulsations upon the left side were natural in frequency, 
while, on the right, they were less frequent, in the proportion of 
three to one." * 

This fact, together with others less authentic, seem to be di- 
rectly opposed to what we have just said; but they only prove 
that, in some cases, the course of the blood may be temporally 
intercepted in one artery, without being so in others, and that, 
owing to the transient obliteration of an artery, intermissions con- 
fined to that vessel may occur. The peculiar lesion which pro- 
duces such an effect, at one time interrupting the course of the 
blood in a vessel, at another, permitting its flow, has not yet been 
ascertained by examination after death, the only means of obtain- 
ing a satisfactory explanation of this phenomenon. 

This differs from those cases in which the pulsations of an 
artery become gradually enfeebled, and at last entirely insensible, 
while those of the corresponding vessel preserve their normal con- 
dition. This difference, which has been particularly observed in 
the radial arteries, is generally owing to the development of a 
tumor in the vicinity of the arterial trunk, compressing it the more 
as it increases in size, and in some cases completely obliterating 
its cavity. This is particularly observed in those cases of aortic 
aneurism, in which the subclavian artery is pressed by the tumor 
against the bony parietes of the chest. 

Such are the principal changes effected by disease in the arterial 
pulsation; many others have been admitted by authors; Galen 
described more than thirty.f To these Solano of Lucca, and Bor- 

* De sedibus et Causis, morb., epist. xxiv. art. 33. 

f The following are the different varieties of pulse admitted by Galen. 

1. Long: in which the artery strikes several, or all four fingers. 

2. Short : in which it strikes but one or two at most. 

3. Large: in which it is increased in diameter. 

4. Narrow : in which it is diminished in diameter. 

5. High : that which seems to raise itself to a point in order to strike the finger. 

6. Low : that in which the pulsations are hardly perceptible. 

7. Great : the artery is increased in length, breadth and elevation. 

8. Small: one whose pulsations are slender and weak. 

9. Quick. 

10. Slow. 

11. Frequent. 



178 SYMPTOMS. 

due have added still others, and have asserted the existence of a 
pulse peculiar to the affections or the crises of each organ ; hut the 
works of these physicians, in other respects, deserving of merit, 
are generally considered as ingenious speculations rather than the 
results of observation. All these minute distinctions of the ars 
sphygmica have been justly abandoned. 

But it is not only important for the physician to admit no alter- 
ations of the pulse but those connected with conditions really ap- 
preciable, such as quickness, fullness, hardness and frequency ; 
but it is also necessary that these alterations should not be noted, 
unless they be very apparent, and such as might easily be recog- 
nized by every physician with senses fitted to receive these impres- 

12. Rare. 

13. Strong: that which strikes the finger strongly. 

14. Feeble : that which strikes feebly. 

15. Hard: the pulp of the finger yields to the pulsation. 

16. Soft : the pulsation yields to the pressure of the finger. 

17. Full: the artery, full and resisting. 

18. Empty: the artery disappears and yields to the fingers ; it has no solidity. 

19. Equal. 

20. Unequal. 

21. Myurus : so called when it sinks progressively, becoming smaller and 

smaller, like a rat's tail (nv?, rat; ovqu, tail). 

22. Deficient Myurus : that which seems every instant about to cease. 

23. Myurus, which diminishes at the two extremities : that which strikes the first 

and last finger less sensibly than those between. 

24. Intermittent: in which the pulsations fail from time to time. 

25. Intercurrent : in which a superfluous pulsation occasionally seems to occur. 

26. Deficient: that which ceases altogether. 

27. P. Caprizans : the pulsation is interrupted in the midst of its diastole, and 

is afterward finished more rapidly than it was commenced. 

28. P Dicrotus: that in which the finger is struck twice at each pulsation, like 

the hammer on an anvil. 

29. Undulating : that which resembles in its movements those of the waves. 

30. Vermicular : the pulsations resemble the progression of a worm. 

31. P. Formicans : these pulsations resemble the motion of an ant. 

32. Tremulous. 

33. Palpitating. 

34. Convulsive : the artery is tense and hard like a cord. 

35. P. Serrinus: that which strikes the fingers unequally, like a saw. 

36. Ardent: that which seems to raise itself to a point, striking the finger 
promptly and forcibly. 

The Chinese physicians, who, it is said, pretend to know the nature and dura- 
tion of a disease by the examination of the pulse alone, have distinguished still 
other varieties. They admit a pecking pulse, resembling the stroke of a bird's 
beak ; another, similar to drops of water falling through a chink, or a frog en- 
tangled in the grass and seemingly unable to advance or go back ; they have 
also a pulse which they compare to boiling water, and another which is flutter- 
ing like a fish continually plunging and afterwards rising so slowly as to enable 
one to catch it by the tail. (Recherches Hist, sur la Medec. des Chinois.) From 
these comparisons we may judge of the others. 

Le P. Leconte remarks that the Chinese physicians before visiting a patient, 
take care to inform themselves of all that he has experienced ; and afterwards 
having examined the pulse for a long time, without asking any question, they tell 
with a prophetic air all that they had previously ascertained. 

The critical pulses will be enumerated in the article on Crisis. 



SYMPTOMS. 179 

sions, and capable of discerning them. The pulse is not necessarily- 
feeble or strong, hard or soft, small or full ; in many cases it pre- 
sents none of these characteristics ; being, according to the expres- 
sion of some authors, moderate. We would not insist on so trival 
a truth, were we not convinced that many physicians have entirely 
neglected it. 

The organs of arterial circulation furnish also other symptoms, 
dependent upon their dilatation or aneurismal rupture ; as the 
pulsations often felt in an aneurismal sac, or in tumors contiguous 
to healthy or diseased arteries ; also their haemorrhages which are 
often fatal, their denudation, wounds, lacerations, and lastly, their 
ossification, which in old persons is often manifest in the superfi- 
cial arteries during life. 

Auscultation has also been applied to the study of the arterial 
pulsations, and has furnished phenomena not without interest. In 
the healthy subject, if the stethoscope be applied over the track of 
an artery, a peculiar dull sound is heard which is isochronous 
with the ventricular systole. This sound, which is caused by the 
impulse of the blood against the wails of the vessel, varies in in- 
tensity, according to the size of the artery and the force with which 
the blood is propelled. This pulsation, this dull sound may, when 
heard in certain regions where it does not normally exist, reveal to 
the physician the existence of a very grave disease, the aneuris- 
mal dilatation of a vessel. So when a simple or double pulsation, 
which is circumscribed more or less forcible, and distinct from the 
pulsations of the heart, is distinguishable upon the anterior and 
superior part of the chest, or behind, near the vertebral column, 
aneurism of the aorta may be suspected. The existence of this 
lesion becomes certain if, at the point where the pulsation is per- 
ceptible, there is also an abnormal sound, as the rasping or bellows 
sounds, and the strength of the pulsation be sufficient to raise the 
hand. 

The bellows sound is, of all the abnormal sounds of the arteries, 
that most commonly observed. It may be feeble or intense, 
continuous or intermittent, circumscribed or diffused ; it may co- 
exist in the aorta, carotids, subclavian and crural arteries, the only 
vessels of the trunk generally ausculted. Sometimes the sound is 
confined to one or two arteries. In other cases, it is but the reso- 
nance or expansion of the same sound produced in the heart, and 
it is often produced in the vessel where it is audible. 

The bellows sound may exist in certain diseases of the arteries, 
as ossification of their parietes, aneurismal dilatation and varicose 
aneurism. It may depend upon compression of the vessel caused 
by a voluminous tumor ; as is observed in cases in which the iliac 
and hypogastric arteries are compressed by an ovarian cyst ; but 
the arterial bellows sound is generally observed in chlorosis, ane- 
mia, and after abundant loss of blood, as in uterine haemorrhage 
and amputations. 

This bellows sound presents itself under various forms, most of 
which have received distinctive appellations. Thus in chlorosis, a 



180 SYMPTOMS. 

sound is audible, particularly in the carotids, to which Bouillaud 
has applied the name bruit de diable, from its resemblance to that 
produced by a child's toy of that name ; in other cases, it resembles 
that of the bellows of a forge ; in others, the cooing of a dove ; 
finally, a kind of whistling is sometimes perceptible, which degen- 
erates, in some cases, into a double toned, and slightly monoto- 
nous, musical humming. This sound was called by Laennec, 
who was the first to describe it, a modulated whistling, or music 
of the arteries. These last varieties of the bellows sound have, 
like the others, been principally observed in cases of chlorosis, 
anemia, and accidentally, in some nervous subjects. 

Within a few years many experiments have been tried and de- 
scribed, in order to explain the mechanism of the arterial sounds : 
When there is dilatation of a vessel, or roughness or unevenness of 
its surface, or when a communication exists between an artery and 
vein by a narrow opening, or finally when the calibre of a vessel 
is diminished by any external pressure, the bellows murmur may 
be naturally explained by the friction of the blood against the 
unequal surfaces or contracted parietes of the vessel. But how 
are these various sounds produced in cases of anemia and chloro- 
sis? This question is unanswerable. It would appear, from 
recent investigations, that rapidity in the motion of the blood, and 
particularly the low density of this fluid, are both conditions 
necessary to the formation of these sounds. * 

The symptoms furnished by the circulation in the capillary 
system and veins, are much less numerous than those observed in 
the arterial circulation. 

C. The florid or livid redness of the skin in the whole or any 
part of the body, marbled appearance, ecchymoses, paleness and 
spontaneous haemorrhages, are all phenomena which belong to the 
capillary circulation. 

Among these phenomena, there are those, such as the florid red 
color of the skin and active haemorrhages, which almost al- 
ways coexist with an evident increase of the vital forces ; they 
have generally been considered as owing to an increased ac- 
tion of the capillary vessels. Others, as the marbled appear- 
ance, livid spots and passive haemorrhages, which ordinarily 
appear in enfeebled persons, are attributed to debility of the same 
system. 

The ecchymoses following contusions, also appear to depend 
upon the capillary vessels, which are moreover the seat of certain 
traumatic haemorrhages, in which the blood flows from the surface 
of a wound. In both these cases, the haemorrhage is owing to a 
rupture or section of the capillary vessels, being entirely independ- 
ent of any increase or diminution in the circulatory force. 

It has been thought, by some authors, that the blood may have 
a retrograde course. The sudden paleness consequent upon a 

♦Memoire de M. de La Harpe, Archiv. Gener. de Medec, 1838. 



SYMPTOMS. 181 

lively emotion or sudden impression of cold, is, according to Spren- 
gel,* entirely inexplicable, unless a rapid retrograde motion of 
the blood in all the arterial and venous vessels, be admitted; but 
this phenomenon may be explained by supposing that the blood 
contained in the capillary vessels is suddenly forced into the veins, 
and that the supply of arterial blood is, at least partially, cut off. 

D. The venous circulation presents some very important symp- 
toms. The veins over the whole surface of the body may become 
distended in certain affections, and particularly in plethora and 
febrile heat ; they disappear, on the contrary, in anemia and in 
the chill which occurs at the commencement of acute diseases, 
and in the paroxysms of intermittent fever. Partial dilatation of 
the veins accompanies various diseases, as local congestions and 
apoplexy, in which the veins of the neck are often enlarged ; it is 
also observed in the vicinity of cancerous tumors, particularly 
those of the mammae ; also in cases of compression of the veins 
of a limb by a tumor: it constitutes one of the most certain signs 
of deep-seated tumors of the thorax or abdomen ; and, in other 
circumstances, dilatation of the veins of the neck, head, chest and 
superior extremities, is the only sign indicative of compression of 
the superior vena cava. We have referred above, to those dila- 
tations of the subcutaneous abdominal veins frequently observed in 
patients suffering from ascites. There are cases in which their 
dilatation is considerable, at the same time that the abdominal 
parietes are indurated ; each of these vessels seems, in such cases, 
to be contained in a solid canal whose angular sides and semicircular 
floor are perfectly distinguished by the finger. M. Raynaud, who 
has called attention to the dilatation of the superficial abdominal 
veins, regards it as indicating the existence of some obstacle to the 
course of the blood in the vena porta, and as the result of a col- 
lateral circulation, by means of which the blood passes from the 
divisions of the inferior, to the superior, vena cava. The post- 
mortem examination of those who presented this peculiarity, does 
not in all cases clearly reveal the impediments to the internal cir- 
culation, pointed out by M. Raynaud ; but some lesion of the 
abdominal viscera is always found, generally consisting in an 
alteration of the liver, known as cirrhosis, a species of atrophy in 
which there is probably some diminution in the diameter of the 
branches of the vena porta, and a modification of the circulation 
in some degree corresponding to the opinion of this physician. 

In certain parts of the body and particularly in the lower limbs, 
in which the venous circulation is rendered more difficult by the 
laws of gravity, superficial, sinuous, knotty tumors of a bluish 
color are often observed, which momentarily disappear by external 
pressure and cold, and increase under the opposite conditions. 
From these symptoms the affection of the veins called varix is at 
once recognizable, a disease in which the length of these vessels 

* Sprengel, Pathol. General, p. 147 
16 



182 SYMPTOMS. 

increases with their size, as is proved by their sinuosities, a phe- 
nomenon not observable in the healthy condition. 

The venous blood may pursue a retrograde course, but this can 
only occur in certain vessels and for a short space. This phenom- 
enon is not uncommonly observed in the external jugular veins, in 
cases of cardiac aneurism. At each contraction of the heart the 
reflux of blood can be distinguished by the eye, its diminishing 
undulations rising often to the upper part of the neck. This symp- 
tom is, by authors, termed a venous 'pulse. There is another 
affection, in which a retrograde flow of the blood in the veins is 
sometimes noticed ; we refer to the aneurismal varix. By means 
of the accidental communication occurring between two contigu- 
ous vessels, a portion of the arterial blood passes into the vein, 
producing in it pulsations isochronous with those of the arteries, 
and giving to the blood an impulse contrary to its natural course, 
the influence of which, however, is felt but a few inches. 

The manner in which the blood escapes differs in wounds of the 
arteries, capillaries and veins. In the first case, it issues with 
force and by interrupted jets ; in the second, it is effused in small 
quantities ; in the third, it may form a continuous jet, the force 
and volume of which varies according to several circumstances. 

A phenomenon noticed by all authors is the absence of hsemor- 
rhage in certain wounds of the vessels ; as in lacerated wounds 
and those inflicted by fire-arms, and more particularly after the 
carrying away of a limb by a projectile ; but this is by no means 
always the case, rapid and fatal haemorrhages having been often 
observed, particularly in gunshot wounds, if any large artery have 
been wounded. 

E. Having now enumerated the principal symptoms furnished 
by the circulation, it remains to consider those furnished by the 
blood itself. This subject, so interesting in a scientific point of 
view, has been almost wholly abandoned since the close of the last 
century, at which time, Parmentier and Deyeux published the re- 
sults of their experiments upon this fluid, and in which the cele- 
brated author of the Nosographic Philosophique sapped to its 
foundations the superannuated doctrine of humorism. Since that 
time, most physicians, convinced that the blood is insusceptible of 
any alteration in the living body, have neglected to make any in- 
vestigations for the purpose of elucidating this important question. 

The treatise of these two celebrated chemists, however, from its 
being opposed to the ancient doctrine, seemed more fitted to attract, 
than to divert, the attention of the learned upon the subject under 
discussion; and if it had the contrary effect, the fault is not so 
much attributable to the work, as to those who lived at the time 
of its appearance. Its influence can only be appreciated by refer- 
ring to that period. 

Its object was to " determine, from modern chemical discoveries 
and accurate experiment, the nature of the alterations which the 
blood undergoes in inflammatory diseases, putrid febrile diseases 



SYMPTOMS. 183 

and scurvy." The experiments were tried; 1, on the blood of a 
young man affected with pneumonia ; 2, on that of three individ- 
uals who presented symptoms of scurvy, connected, in two, with 
general plethora, and with pain in the side in the other; 3, on 
the blood of a certain number of individuals suffering from affec- 
tions vaguely designated by the term 'putrid fevers, in many of 
which no putridity existed. 

Let us suppose for a moment that the results of the observations 
and experiments made on this small number of patients had all 
been contrary to the doctrine previously admitted, would they suf- 
fice to overthrow it? Certainly not; and we do not hesitate to 
say, that an opinion which had been held for so many centuries, 
and had withstood so many contending systems and theories, de- 
served a more thorough examination before discarding it. This 
should only be accomplished by a mass of well observed facts. 
Now, the treatise in which it is undertaken to proscribe it, contains 
but a single fact, and that favorable to the opinion it combats. 
The other experiments undertaken in the cases of scurvy demand- 
ing bleeding, and putrid febrile diseases, many of which did not 
present this character, do not afford the necessary conditions to 
serve as a base for rigorous conclusions. 

Let us now pass to the results of these experiments. 1. Chemi- 
cal analysis showed no difference between the blood in pneumonia 
and that in scurvy ; but, without here referring to the uncertainty 
inherent in chemical analyses, the results of which vary with the 
progress of the science, we should recollect that there are many 
natural, and, particularly, organized, bodies, which are distinct 
from each other in their physical properties and their action upon 
the economy, although no such difference is indicated by chemical 
reagents. This remark, the truth of which is sufficiently evident, 
should suffice to put us on our guard against the hasty application 
of chemistry to organized bodies ; chemical analysis may show no 
difference between the blood of scorbutic patients and that of 
persons suffering from an inflammatory disease, although it may 
be as great as between wholesome and poisonous substances, 
which, by chemical examination, are undistinguishable from each 
other, as the phlegmonous and variolic pus, for example, which is 
susceptible of producing very different effects upon the economy. 
2. In regard to the physical properties of the blood, its consistence 
and the formation of the buff, Parmentier and Deyeux observed 
that they were not constantly tlie same in similar affections, and 
were sometimes alike in diseases of an opposite nature. From the 
careless manner in which the diseases are characterized in this 
treatise, we should be cautious in regard to the conclusions deduced 
from these results. 

Our only object in thus appearing to criticise this treatise, was 
to combat the consequences which have arisen from it, and which 
would, perhaps, be disclaimed by the authors themselves. They 
justly called in question an opinion the truth of which had not been 
previously doubted, and are not responsible for errors which they 



184 SYMPTOMS. 

did not inculcate. We have not maintained an opinion contrary 
to that which they expressed ; we have only proposed to bring the 
question back to where it should be, and call the attention of 
faithful observers to a subject too hastily abandoned. Without 
waiting for new facts to shed more light on this obscure point in 
pathology, we will consider the less doubtful points respecting it. 

We thus expressed ourselves in 1817, and again in 1824, respect- 
ing the hitherto contested alterations of the blood in the course of 
diseases. Since that time there has been an entire change of opin- 
ion upon this interesting subject. The fluids of the economy, and 
particularly the blood, have been the subject of curious researches 
both by chemists and distinguished physicians, which seem to 
promise important results. 

Some experimenters, and particularly Rossi and Bellingheri, 
have compared the electrical state of the blood in health and dis- 
ease ; but the result of these researches, which need to be confirmed 
by others, has, as yet, afforded no useful indication in diagnosis 
or therapeutics. 

The blood, in disease, presents other more apparent changes, 
which we shall proceed briefly to consider. 

While the blood circulates in its vessels, it escapes our observa- 
tion, and cannot consequently be submitted to examination ; it is 
only when it flows from the body that its physical properties 
become apparent. 

The qualities of the blood can rarely be correctly appreciated 
in spontaneous haemorrhages. This fluid, in issuing drop by drop, 
is coagulated in small masses, so that its color and consistence are 
alone appreciable ; and even these may be with difficulty deter- 
mined, if, as is often the case, the blood be mixed with other 
matters. It is only in blood-letting, in which a certain quantity 
of this fluid flows rapidly from a vessel of medium size, that all 
its qualities become appreciable. The force with which the blood 
escapes, in the operation of phlebotomy, deserves attention, par- 
ticularly in its two extremes. Thus, in vigorous subjects, the jet 
is strong and continuous, while in those suffering from debility, 
the blood flows slowly, with difficulty and often guttatim. hi 
the cold stage of cholera, the slowness with which the blood issues 
from an incision of the veins, and even arteries, is owing not only 
to the diminished contraction of the heart, but also to the thick- 
ness, viscidity, and almost gelatinous state, of the blood. The 
sound which is supposed to accompany the issue of the blood, and 
the quantity of froth which appears upon its surface in the cup, it 
is unimportant to notice. Its color can only be distinguished while 
flowing; its contact with the air, and particularly its separation 
into different parts, soon produce marked changes in its appear- 
ance. It is more red in inflammatory diseases than in adynamic 
affections and scurvy, in which it is of a blackish hue, and dis- 
eases of debility, as chlorosis, anemia and dropsy, in which it is 
generally pale. Some physicians, Huxham among others, assert 
that they have perceived in the blood at the moment of its escape 



SYMPTOMS. 185 

from the vein a fetid odor in those affected with putrid fever ; 
these assertions require confirmation. Nevertheless, such an odor 
may possibly have been noticed, if, as has recently been advanced 
by Dr. Bonnet of Lyons, * the blood in typhoid fever contains 
hydrosulphate of ammonia, a salt detected by Vauquelin in pu tri- 
fled blood, and it be true that in some cases of anthracoid 
diseases, a spontaneous development of the hydrosulphuric acid 
takes place in this fluid, f Pringle also recognized a putrid odor 
in blood newly drawn.| Some authors have asserted that this 
fluid exhales a urinous odor in retention of the urine, but this 
opinion has not yet been verified. || 

In health, the blood has a saltish taste. It has been supposed, 
by some authors, that, in diabetes, this peculiarity was less marked, 
and some have asserted that the serum exhibited a sweetish taste 
(Dobson). M. Guibourt found, upon examination of diabetic 
urine, the serum to possess the ordinary flavor. 

The temperature of the blood may be modified in certain dis- 
eases. Thus in those affected with cholera, it was generally lower 
by four or five degrees (Reaumur) than in other diseases. 

The blood, allowed to remain at rest for a few hours, ordinarily 
separates into two parts : the se?-um, and the coagulum. The pro- 
portion, between the coagulum and serum, varies according to 
different circumstances, some of which only are known. The 
serum is generally less abundant at the commencement of inflam- 
matory fevers and the phlegmasia?, sometimes being wholly absent ; 
the blood, in these cases, is said to be rich ; but towards the latter 
periods of the disease, the coagulum becomes smaller and the 
serum more abundant, in proportion to the number of times blood- 
letting has been performed ; sometimes also a portion of the serum 
remains in the coagulum, which can only be squeezed out by pres- 
sure. In these cases, the coagulum is softer than when spon- 
taneously disengaged from all the serum, and if it exhibit a buff, 
this is thicker from being infiltrated with serum. 

The quantity of serum, which is small in robust persons, is con- 
siderable in those of feeble constitution, but particularly in those 
affected with anasarca and chlorosis, and also in those who have 
submitted to repeated blood-letting : in these cases the blood is said 
to be poor. In the latter, the serum is pale and free from the citrine 
color which is natural to it ; it appears that the soluble salts which 
it generally contains, are found in less proportion. This has been 
also observed in Bright's disease ; for it results from the experi- 
ments of Dr. Christison that, from the first period of this affection, 
there is a great diminution in the density of the serum, which 
depends upon a more or less considerable reduction in the propor- 
tion of albumen and salts. In consequence of this loss of albumen, 

* Gas. Medic, t. v. p. 601. 

+ Nouv. Biblioth. Medec. 

\ Maladies des Armces, p. 388. 

|| Maladies des Reins, t. 1, p. 227. 

16* 



186 SYMPTOMS. 

the serum of the blood is less coagulable by heat, * while an 
opposite change takes place in the urine. 

The serum may also contain various substances which can only 
be discovered by inspection or chemical analysis. Thus it is 
sometimes of a reddish color, owing to a portion of the coloring 
matter of the blood which it contains, a circumstance, according 
to some authors, indicative of a state of general debility or a 
cachectic condition. In bilious diseases, particularly jaundice, 
the serum presents a yellow or greenish tint, which, in some 
cases, precedes the change in the color of the skin by several 
days, and indicates the presence, in the blood, of the coloring mat- 
ters of the bile. According to some chemists, the existence of 
cholesterine (Boudet) and picromel (Orfila) has been detected in 
these cases. 

The serum sometimes presents a milky appearance, as was 
observed by Christison in the first period of Bright's disease, and, 
by Marshall Hall, in the blood which last flowed from animals 
dying from haemorrhage. Some physicians were for a long time 
deceived by this milky appearance of the serum, for they supposed 
that the blood contained this fluid in substance, or at least, its 
material principles ; but modern chemists are unanimous in attrib- 
uting this peculiar appearance of the serum to the presence of 
fatty matters in suspension, which are easily separated by means 
of ether. 

In cases of urinary absorption, and in the first and last periods 
of the granular disease of the kidneys, the serum contains a con- 
siderable quantity of urea (Christison, Rayer, Rees). Some chem- 
ists have detected the same substance in the blood in cholera, 
particularly in cases in which the urinary secretions was suspended 
(Hermann,! O'Shaughnessy J). It has been recently advanced 
by Dr. Copland, that urea is found in great abundance in the blood 
of persons suffering from gout; § but this assertion of the English 
pathologist has not as yet been confirmed. 

Many physicians or chemists, among whom we may mention 
Rollo, Rees, Dobson, M'Gregor, and M. Bouchardat,|| assert that 
they have discovered in the blood of diabetic patients, a consider- 
able quantity of sugar ; but these results were formerly contested 
by Nicolas and Guedeville, 11 Vauquclin** and Wollaston, ff and 
more recently by M. M. Henry, SoubeiranJJ and Guibourt; |||| 
this question is not yet finally settled. 

The coagulum varies in its form, consistence and the peculiar 

* Archiv., 3d series, t. iv. p. 472. 

f Bull, des Sc. Med. de Ferussac, t. xxvii. p. 7. 

% Gaz. Medec, t. iii. p. 109, 1832. 

is Dictionary of Prac. Med. art. Blood. 

|f Revue et Journal des Connaisances Mcdicales, 1839. 

•ff Diab. sucr'e. Pans, 1803. 

** Journal de Chimie, t. i. 

\] Phil. Trans., 1811. 

\\ Journ. de Pharm., t. xii. p. 320. 

|||| Raver, t. i. p. 244. 



SYMPTOMS. 187 

appearance of its surface. Its form is generally that of the vessel 
into which the blood is received, that of a disc flat upon its su- 
perior, and convex upon its inferior, surface. In some cases, the 
superior surface becomes concave from inversion of its edges ; the 
blood is then said to be cupped : it is particularly when the coagu- 
lum is small that it presents this form, this occurring chiefly in 
the second period of inflammations and after repeated blood-letting. 
Much importance has been attached to the consistence of the 
coagulum. It is generally firm in inflammatory diseases, and in 
robust subjects ; it is, on the contrary, soft in chronic affections, 
anemia and chlorosis ; it is diffluent in cases of miasmatic poi- 
soning, in the last stage of grave fevers, in certain eruptive fevers, 
and, particularly, in confluent variola, the severest form of scar- 
latina, &c. The blood, in the cold or blue stage of cholera, is 
black, viscid, resembling current jelly, and reddening but slowly, 
by exposure to the air. Increase in the density of the clot, its 
volume, and the small quantity of serum, indicate an abundance 
of globules ; paleness of the coagulum, denotes a diminution of 
the coloring principle, and consequently the iron with which it is 
combined. 

Is there a condition of the clot which is characteristic of any 
disease '} Can it be admitted, for example, that a soft and diffluent 
and curdy coagulum, or a serum holding in suspension a portion 
of the coloring matter of the blood, are lesions characteristic of 
typhoid fever'.' We think not. We cannot indeed regard, as pe- 
culiar to typhoid fever, those alterations which often fail, particu- 
larly in the first stage of this disease, the only period when 
blood-letting is generally practicable, and which we have often 
observed in other diseases. 

The surface generally differs in appearance from the rest of 
the coagulum; it is distinct in color and nature, and of variable 
thickness. In health and many diseases, this surface is of a rosy 
or vermilion color in the thickness of a half a line or a line. In 
inflammations, and particularly those of several days' duration, 
the blood is almost constantly covered with a crust of a greater or 
less thickness and solidity, often lardaceous, to which the term 
inflammatory crust or buff has been applied {crusta injlammatoria). 
This buff is so frequent in the thoracic phlegmasia} that, by many 
authors, it has been called the pleuritic crust {crusta pleuritica). It 
also almost constantly exists in rheumatic fever, and very fre- 
quently in most acute diseases accompanied with intense lever. 
The buff does not, however, necessarily indicate the existence of a 
phlegmasia, since it occurs in the blood of plethoric persons, 
otherwise healthy, and almost always accompanies pregnancy. 

The thickness and firmness of the buff, is generally in propor- 
tion to the violence of the inflammation and the robustness of the 
individual. It is almost always of a greyish white color : it is of 
a rosy hue when thin, and yellow when the serum in which it 
floats presents this color. By pressing it, a few drops of serum 
can generally be squeezed out. The formation and thickness of 



188 SYMPTOMS. 

the buff do not exclusively depend upon the qualities of the blood; 
they are in part owing to the manner in which it flows out and 
the form of the vessel into which it is received. If it flow slowly, 
it coagulates in falling, as has been before remarked, and forms an 
homogeneous mass in which neither coagulum, serum nor buff can 
be distinguished. If it flow in a jet from a narrow opening, the 
conditions are more favorable, and a buff may be formed ; but it 
is generally thin, and the serum is but imperfectly separated from 
the coagulum ; if the blood flow in a full stream and from a large 
opening, the separation of the elements of the blood takes place 
more readily, and the buff which it presents is of a thickness and 
consistence proportionate to the richness of the blood. These dif- 
ferences often appear at a single bleeding, if the blood be allowed 
to flow into several cups and with unequal force, as often happens. 
It is sometimes possible to judge from the different thickness of the 
buffy coat in various points of its extent, that there has been great 
inequality in the flow of the blood. Finally, the thickness of the 
buff varies with that of the clot; that is, the thickness of the layer 
of blood drawn from the veins, which depends upon the form of 
the receiving vessel. If, for example, in bleeding a patient, four 
ounces of blood be drawn into a plate, the buffy coat is only one 
or two lines in thickness ; half of this quantity, received in a 
tumbler, would present a buff five or six lines in thickness. 

There is another circumstance that exerts a marked influence 
upon the thickness of the buffy coat ; we refer to the manner in 
which the separation between the serum and coagulum is effected. 
This separation, which is never absolutely entire, so varies, that 
in some cases, the clot contains twice the quantity of serum as in 
others. Now, the buff is never so thick as when infiltrated with 
serum. This disposition is at once apparent from the transparency 
of the buff, and the facility with which the fluid escapes ; if the 
finger be placed underneath the clot so as to raise it, a multitude 
of small drops are at once visible on the surface of the buff, which 
rapidly increase till they unite by their circumferences and flow 
of. We have sought to ascertain the causes which produce this 
retention of the serum by the coagulum; but from the different 
experiments which we have made by varying the form and, in 
some cases, the temperature of the vessel into which the blood was 
received, and taking into account the size of the opening in the 
vein, the force with which the blood flowed out, and the nature of 
the affection from which the patient suffered, we have been able 
as yet to learn nothing respecting the conditions necessary to the 
production of this phenomenon. 

The existence of a buffy coat, according to most authors, indi- 
cates an increase in the proportion of fibrine; according to others, 
a modification of the albumen ; there are also many who attribute 
it to a matter spontaneously coagulable. The production of this 
phenomenon is enveloped in much obscurity. 

The blood may contain various deleterious principles, some of 
which are discoverable by chemical reagents; thus, Orfila has been 



SYMPTOMS. 1S9 

able to detect the presence of arsenious acid in the blood of those 
poisoned by this substance. There are other deleterious princi- 
ples which can alone be suspected to exist in the blood : thus in 
the inoculation of the contagious and eruptive diseases, every- 
thing indicates that, between the insertion of the virus and the 
development of the symptoms, the blood undergoes some alteration, 
the detection of which is beyond the reach of physical or chemi- 
cal exploration. The presence of the virus of rubeola in this 
liquid, would have been shown by the experiments of Fr. Home 
and Sparanza, who inoculated rubeola with the blood of those 
affected with this disease, if these experiments had been repeated 
a sufficient number of times, by different experimenters with the 
same success, and with all the necessary precautions. 

If, as is proved by the observations of modern chemists, the 
blood in its normal condition contain oxgyen, azote and carbonic 
acid in a free state, it is probable that many alterations in this 
fluid may depend upon a change in the normal proportion of these 
gases. Dr. Clanny has pretended that the blood in typhoid fever, 
contains less carbonic acid, and consequently advises the use of 
Seltzar water. * But, on the one hand, the opinion of Dr. Clanny 
upon this alteration of the blood needs confirmation ; and, on the 
other, respecting the curative method proposed by him, we may 
remark, that having treated a great number of patients, at La 
Charite, by the exclusive employment of gaseous drinks, no more 
cures were obtained by these, than by cooling and acidulated 
drinks. 

Such are the principal alterations furnished by the blood in dis- 
ease ; if there be many, which are doubtful, there are others, 
too evident to admit of question. All physicians are, at the pres- 
ent day, convinced of the necessity of studying these alterations, 
which are already of interest, and promise henceforth results of 
immeasurable importance. 

The microscopical characters of the blood, both in health and 
disease, have also been recently investigated. But as no positive 
results have yet been obtained from these researches, as experi- 
menters have arrived at different and often contradictory conclu- 
sions, we abstain from giving opinions which need confirmation. 
We shall only premise to those engaged in these investigations, that 
the blood-globules readily undergo an alteration during the 
formation of the clot, and that hence it becomes necessary to defi- 
brinate the blood as it issues from the vein; in this way a fluid may 
be obtained, which is easily preserved for a considerable time, and 
in which the properties of the globules remain unchanged. 

$ I. Circulation of Lymph. The phenomena which occur in 
the lymphatic vessels, it is rarely possible to appreciate. The 
redness which sometimes makes its appearance in their course, 
and their hard and knotty feel, are symptoms of their inflamma- 

* A Lecture upon typhoid fever. Lond. 1828. 



I 90 SYMPTOMS. 

tion. Many cases have been cited in which they presented dila- 
tations similar to those in varicose veins. But, generally, the 
alterations of lymphatic vessels are not appreciable till after 
death. 

The lymphatic glands which, with the vessels of the same 
name, concur in the circulation and elaboration of the lymph, 
present symptoms more apparent. They often become increased 
both in volume and sensibility, a phenomenon to which the term 
engorgement has been applied, and which may appear in an acute 
or chronic form. This engorgement of the lymphatic glands 
almost always follows a lesion of some part, in greater or less 
proximity, and more frequently, the application of virus or some 
acrid substance to the parts from which the lymphatic vessels, be- 
longing to these glands, take their rise. In erysipelas of the face, 
the submaxillary glands are the seat of a painful swelling, which 
also occurs in some cases of angina, and particulary those termed 
couenneuses. Chronic eruptions of the scalp, the difficult extrac- 
tion of a tooth, and dental caries, are frequent causes of a chronic 
and often circumscribed engorgement of the same glands and those 
upon the side of the neck. Acute engorgement of the axillary 
glands, ordinarily arises from an excoriation, a prick of the fingers, 
particularly if the wound be inoculated with putrid matter, as 
is too often the case in those who wound themselves in dissecting, 
or who, having a scratch or excoriation upon the hand, bring it in 
contact with an irritant and septic fluid, as pus or sanies. In 
other cases, the glandular engorgement is owing to a phlegmasia, 
wound, ulcer or blister upon the corresponding side of the chest. 
In nursing women, diseases of the mammary gland are a frequent 
cause of a painful engorgement in the axillae. The glands of the 
groin, also, become frequently inflamed, and from the precise seat 
of the engorgement, we may often determine whether it be symp- 
tomatic of a lesion of the genital organs, the corresponding limb 
or the inferior part of the trunk. If it exist in the internal part of 
the groin, some disease of the genital organs should be at once 
suspected, because it is in this part of the inguinal region that the 
lymphatic vessels which arise in the sexual organs, all centre. If 
the engorgement occur at the inferior and external part of the 
groin, it generally depends upon a lesion of the lower limb, as a 
wound or excoriation upon one of the toes, produced by walking 
or some other cause. If it is the superior lymphatic glands that 
are inflamed, the cause must be sought in the abdominal parietes. 
Lastly, if the phlegmasia is confined to the external side of the 
inguinal region, the corresponding thigh, which is generally the 
seat of the cause which produces the engorgement, should be 
examined. 

It seems then that inflammation of the lymphatic ganglia gen- 
erally succeeds an evident cause of irritation, more or less remote. 
But, there are cases in which the glands become inflamed and 
painful, independently of any perceptible alteration of texture or 
color in the neighboring parts. The occurrence of a glandular 



SYMPTOMS. 191 

engorgement under these circumstances, when accompanied with 
fever, generally indicates the speedy development of erysipelas 
upon some not far distant part of the integuments ; thus if it be 
the submaxillary or cervical glands that become affected, the 
erysipelas will manifest itself upon the head ; if the axillary 
ganglia or those of the groin, its appearance upon the superior or 
inferior limb may be expected. In those cases where a glandular 
engorgement precedes the inflammation which it ordinarily accom- 
panies as a secondary phenomenon, it is probable, that, although 
there be no change perceptible to the eye, or pain experienced by 
the patient, a modification already exists in the capillaries of the 
lymphatic or circulatory system, the first effect of which is inflam- 
mation of the glands. 

When the swelling of the subcutaneous and subaponeurotic 
glands is very considerable, occupying many at once, and the in- 
flammation of which extends to the surrounding cellular tissue, 
the inflammatory tumor is called a bubo, a word particularly 
applied to engorgements in the groin and axillary regions, and 
sometimes to those of the neck and ham. When primary, a rare 
circumstance, or depending upon a non-specific irritation, more 
or less remote, they are called simple. They are termed syphilitic 
and pestilential when caused by the virus which constitutes these 
two affections : the former, are generally seated in the groin and 
connected with the existence of chancres upon the external organs 
of generation ; the latter, which are particularly observable in the 
East, may appear wherever a certain number of glands exist 
grouped together, as in the groins and axillae, sometimes in the 
ham and cervical region, and more rarely in the cheeks ; it would 
appear from the examination of bodies after death, that the deep 
seated glands, in front of the vertebral column, often participate in 
the engorgement of the superficial glands.* Syphilitic and pestilen- 
tial buboes frequently terminate by suppuration. This termination 
is rare, on the contrary, in simple buboes. When chronic engorge- 
ment of several glands exists simultaneously in different regions, 
presenting a chronic form, it denotes some constitutional affection, 
generally a scrofulous taint. 

A peculiar symptom sometimes presented by the lymphatic ves- 
sels and glands, is a discharge of colorless fluid, following suppu- 
ration or wounds of their tissue, which in some cases persists for a 
long time, as is occasionally observed after syphilitic inflammation 
of the inguinal glands. 

In regard to the alterations of the lymph, its consistence, acri- 
mony, &c., they have never been definitely determined : analogy 
would lead us to suppose that this fluid, like all those which enter 
into the composition of the human body, is susceptible, in disease, 
of undergoing various modifications ; but these modifications have 
not hitherto been the subject of serious investigation, being a 
branch of research so entirely new and the difficulties with which 

* Dela Peste orientate, etc., par Bulard. Paris, 1839. 



192 SYMPTOMS. 

it is surrounded so great, that its elucidation can only be effected 
by means of experiments performed upon healthy and diseased 
animals. 

SECTION FOURTH. 

Symptoms furnished by Animal Heat. 

The faculty by which the human body, in the healthy condition, 
is enabled to maintain a uniform degree of heat, whatever be the 
temperature of the surrounding medium, becomes still more appa- 
rent in disease. In health, the heat of the body is always in- 
creased to a certain extent when exposed to a temperature higher 
than its own ; it becomes diminished under the opposite conditions. 
In disease, on the contrary, the body may become chilled notwith- 
standing the employment of warm applications; the heat may also 
become burning, without being affected by the ingestion of cool 
drinks, or the removal of clothing. Under other circumstances, 
patients become morbidly susceptible of the influence of cold and 
heat. 

The appreciation of morbid heat, as of many other symptoms, 
requires on the part of the physician long experience, which can 
only be attained by close observation and the frequent comparison 
between normal and abnormal heat, in the various conditions of 
health and disease. The best instrument that can be employed, is 
the hand. We are sometimes enabled by the thermometer to 
ascertain the exact degree of the heat of the body; but this instru- 
ment is entirely unfitted to show the other modifications sometimes 
presented by abnormal heat. In many cases, indeed, we are 
enabled to perceive a manifest increase of temperature, although 
that indicated by the thermometer is not above the usual standard 
of the blood in health. This is particularly evident from the 
experiments of Hunter, who, having produced an artificial inflam- 
mation in the vagina and rectum of ail ass, in the chest and 
abdomen of a dog and slut, was unable, in any of these cases, to 
distinguish by means of the thermometer the slightest elevation of 
temperature, whilst its increase was perceptible to the touch.* In 
order to appreciate the varieties presented by the animal heat, the 
hand employed should be moderately warm ; it should be applied 
successively to various parts, and particularly to the extremities 
of the limbs, face, chest, abdomen, and over the region which 
appears to be the seat of the disease or predominant symptoms ; it 
should be allowed to remain in contact with each of these parts, 
for twelve or fifteen seconds, in order to ascertain if the sensation 
transmitted to it, remains the same or differs by prolonged contact. 

It has been said that the animal heat is, generally, more consid- 
erable in children than adults ; that it is always less in the morn- 
ing, becomes sensibly increased in the middle of the day, and is 

* Hunter (John), .4 Treatise on the blood and inflammation. Lond. 1794, 4to. 



SYMPTOMS. 193 

more elevated in the evening than at any other period; that during 
calm sleep, the temperature is diminished by four or five degrees, 
and at the moment of awaking, is sensibly increased, &c. ; but to 
all these rules established by semeiologists, there are numerous 
exceptions. 

There are four principal modifications presented by the heat in 
disease, it may be increased, diminished, abolished or perverted. 

A. The heat may be more or less increased in different diseases, 
or in different periods of the same disease. Between the slight 
heat which occurs in many light affections, and the burning heat 
observed in the most violent febrile diseases, there are various 
shades. 

In some cases, the heat is alone sensible to the patient, in others, 
it is perceptible to the hand of the physician, or can be measured 
by means of the thermometer. Some experimenters assert that 
they have been thus enabled to distinguish an elevation or diminu- 
tion of temperature of several degrees. Thus in some cases of 
typhoid fever, the temperature has been known as high as from 
33° or 34° c. to 40 or 41°, * while in cholera, according to the 
experiments made at Vienna, the temperature of the feet was as 
low as 14°, Re., and that of the tongue 15°. There is no disease 
in which the temperature is so low as in cholera, f 

The heat may be general or partial ; in the first case, it may be 
distributed equally over the whole body, or, as is most common, 
be more elevated in certain regions. When the heat is confined to 
a single region, it is sometimes in the diseased organ itself that it 
appears, and sometimes in a part more or less remote, as the head, 
in certain affections of the stomach, and the palms of the hands 
in some diseases of the lungs. The skin, which covers a 
phlegmon, is almost always very warm, and the heat of the fore- 
head is often more or less elevated in cephalgia. It has been 
asserted that the integuments of the abdomen and thorax also 
become thus affected in the phlegmasia? of the organs contained in 
these cavities, as is the case with the skin of the forehead in some 
cerebral affections ; but here the analogy is fallacious. In most dis- 
eases, and particularly febrile affections, the degree of heat sensible 
to the hand, is greater in the regions of the chest and abdomen, 
than at the extremities : this difference even exists in those cases 
in which the seat of the disease is remote from these two cavities ; 
and in the phlegmasia? of the lungs, the integuments of the abdo- 
men are as warm as those of the thorax. 

The heat presents analogous varieties, in relation to its type : it 
sometimes continues uninterruptedly during the whole course of a 
disease; it sometimes reappears periodically, as in intermittent 
fevers, or at irregular intervals, being of transient duration 
in females suffering from disordered menstruation, and nervous 

♦Bouillaud, Clin, de la Charite, t. 1, p. 294. 
| Gaymard and Gekardin, p. 121. 

J7 



194 SYMPTOMS. 

persons; in these cases it comes on in flushes, according to the 
common expression; these flushes ordinarily occur in the face; 
they are accompanied by redness of the part, and are frequently 
followed by gentle perspiration. The partial and transient heat 
which is sometimes felt in different parts, moving rapidly from one 
to another, has, by authors, been termed nervous or erratic. 

The heat, in disease, presents still other differences in relation to 
the peculiar character which it offers; it sometimes resembles that 
of a healthy person when warm: this is called free heat; when 
accompanied by moisture, like that felt by a person after a warm 
bath, it is called moist ; if the skin have lost its suppleness and 
ordinary degree of moisture, the heat is termed dry ; it is burning, 
when there is dryness together with a high degree of temperature ; 
it is acrid and pungent, when it conveys to the fingers a disagree- 
able sensation, well expressed by the epithet, and which instead 
of diminishing, increases by prolonged contact, and which con- 
tinues for some time after this has ceased. Some authors have 
described other varieties, which they have termed hectic, and sep- 
tic, heat ; but these secondary shades are of difficult and uncertain 
appreciation, and, as it is impossible to give an idea of them by 
words, we shall only mention them as belonging, the one to hectic 
fever, the other, to parts affected with gangrenous inflammation. 

B. Diminution of heat, or cold, presents the same varieties in re- 
lation to its intensity, seat, type, and peculiar character. 

Cold may be appreciable by the physician, or be only sensible to 
the patient, in both cases its intensity may vary. Coldness is a 
simple sensation of cold ; horripilation, a sensation accompanied 
with bristling of the hairs over the body (goose flesh) ; when 
attended with an involuntary tremor, it is called a rigor. A chill 
may be general or partial, external or internal, transient or con- 
tinual, with or without exacerbation. Senac speaks of a fever 
patient whose arm alone was cold. In regard to its peculiar char- 
acter, it may be stinging, icy, or similar to that experienced by a 
healthy person when exposed to the cold air. 

Partial cold almost always affects the extremities, end of the 
nose, back and loins. It is also, but very rarely, seated in the 
affected organ, as is sometimes observed in chronic rheumatism. 

A chill of greater or less intensity generally marks the com- 
mencement of most of the phlegmasia. If violent, and occurring 
in a person previously in perfect health, it indicates, particularly 
in the winter and spring, when these diseases are most frequent, 
an attack of pleuro-pneumonia, and should lead the physician to 
fear its development, even before the appearance of any other local 
sign, and when there are considerable disorder of the stomach, or 
brain, to direct our suspicions elsewhere. This phenomenon has 
alone enabled us, in many cases, to prognosticate an inflammation 
of the lungs, which did not become distinctly apparent till after one 
or two days of fever. 

Intermittent fever commences also by a rigor ; but this is gen- 



SYMPTOMS. 195 

erally accompanied by a general tremor, which is not commonly 
observed at the commencement of the phlegmasia?. When the 
phlegmasia terminates in suppuration, irregular chills supervene, 
which proceed from the inflamed organ (Landre-Beauvais). Rigor 
is often the index of an abundant suppuration, and, according to 
Baillou, the absorption of pus into the blood.* Dance observed 
the same phenomenon in phlebitis, when the pus had made 
its way into the circulatory torrent. In these cases, there are vio- 
lent chills, which, in some subjects, recur with a kind of periodi- 
city, as in intermittent fever. 

In a great number of cases, there is an alternation of cold and 
heat in the same individual, the chill generally occurring first, 
followed by the heat; the contrary is sometimes observed. Dimi- 
nution and increase of temperature often succeed each other many 
times within a short period. 

C. The complete abolition of heat only occurs in cases of freez- 
ing which may be partial or general ; it is probable that the tem- 
perature is nearly as low, even in parts susceptible of complete 
restoration. However, we know of no fact of this kind in which 
the degree of heat was measured by the thermometer. 

D. The heat is perverted in all cases in which the patient com- 
plains of a sensation of cold in a part which is evidently warm, or 
a sensation of warmth in a part which is cold. The latter phe- 
nomenon often occurs in dry gangrene of a limb. The patient 
complains of burning heat in the affected part, while to the assis- 
tants it feels cold. To this disorder of the heat may be referred 
those sensations of external and icy coldness and internal heat, 
sometimes simultaneously felt, and vice versa. We have seen at 
La Charite, in one of the wards of Lerminier, a case still more 
extraordinary, that of a young man who had been for some 
time suffering from intermittent fever. At the moment that he 
experienced the rigor, that is, a sensation of cold with general 
tremor, his skin became red, warm, and covered with a profuse 
sweat. This singular phenomenon occurred during several succes- 
sive paroxysms. 



SECTION FIFTH. 

Symptoms furnished by the Exhalations and Secretions. 

The act by which certain fluids are separated from the blood by 
means of the various organs, is called secretion. Of these, there 
are two kinds ; those that occur in all parts of the body, and par- 
ticularly on the free surface of different membranes, and are com- 

* Ballo. Consul, lib. 1, p. 110. 



196 SYMPTOMS. 

prised under the term exhalations ; and those, which have partic- 
ular organs, furnished with excretory ducts, and which have been 
more properly called secretions. These will be considered succes- 
sively. 

§ 1st. Exhalations. 

The exhalations not only serve the purpose of maintaining the 
suppleness, preventing adhesion, or favoring the motion of the 
membranous surfaces upon each other ; they act a still more im- 
portant part in the general equilibrium ; they prepare, by elabora- 
tion of the fluids, materials for nutrition. We shall not attempt to 
follow physiologists in their discussions upon the form and modus 
operandi of the exhalent organs ; the exhalent fluids, alone appre- 
ciable to the senses, are what particularly should claim the atten- 
tion of the physician. 

The symptoms which depend upon the exhalations may be 
divided into three groups ; to the first, belong the various changes 
which supervene in the natural exhalations, as those which occur 
in health ; to the second, may be referred the phenomena peculiar 
to the morbid exhalations ; we class, in the third series, all that 
relates to artificial exhalations. To the first series, belong the 
cutaneous, mucus, serous, synovial, fatty, menstrual, and certain 
other natural, sanguineous, exhalations ; to the second, the exhala- 
tion of blood, pus, and some other fluids ; the exhalation furnished 
by blistering and cauteries, will be ranked in the third series. 

A. Natural Exhalations. 

1. The cutaneous exhalation, or perspiration, in health, is con- 
stant, gentle, and equal in all parts of the body. It becomes, at 
intervals, more abundant, constituting sweat, which is always ex- 
cited by an evident cause, as heat of the atmosphere, exercise, a 
violent emotion, &c. 

In disease, this exhalation may be undisturbed, preserving the 
suppleness peculiar to the cutaneous surface. When moderately 
increased, it produces moisture {ma dor) upon the skin. If the in- 
crease is more considerable, so that the fluid appears in drops upon 
the surface of the skin, and moistens the clothes, it is called sweat 
{sudor). This may be general, or partial ; in the first case, it is 
everywhere equal, as towards the decline of acute affections ; 
sometimes it is more abundant on the neck, chest, and forehead, 
as is observed in phthisis. When partial, it is often confined to the 
palms of the hands, epigastrium and forehead. Sweating of the 
hands and feet is habitual in some persons. Its sudden suppres- 
sion has always been thought to be the cause of severe accidents, 
as would appear from the observations recently published by Dr. 
Mondiere.* 

* V Experience, 1839. 



SYMPTOMS. 197 

The temperature of the sweat may be mild, elevated or low ; the 
latter is generally an unfavorable omen. 

The sweat presents numerous varieties in relation to its density 
and color ; it is sometimes thick, viscous and even pitchy as in the 
dying, and sometimes thin and watery ; it is generally colorless ; in 
some cases, it imparts to the linen worn a yellow tinge, in others, 
it has been red (suews de sang). Cases have been also cited by 
Borelli. Borrichius and Fourcroy, in which the sweat was of a 
bluish or black color. The sweat differs in other respects ; it may 
be slight, moderate, abundant, transient, continual or periodical ; 
it may be solely the effect of disease, or be excited by particular 
causes, as a change of position, cough, warm drinks, &c. ; it may 
relieve or enfeeble the patient, sometimes producing fatal results; 
it is, in this case, called colliquative {sudores colliquativi) ; this 
may appear at the commencement, towards the middle or decline 
of diseases, or continue through their whole course. It consti- 
tutes the predominant symptom in certain affections ; as in the dia- 
phoretic, pernicious, intermittent fever, so well described by Torti, 
and to which he came near perishing a victim. Abundant sweating 
is one of the principal symptoms in the sudor picardicus, and it was 
also observed in that terrible epidemic, the sudor angllcus or sweat- 
ing sickness, which in the middle ages ravaged a part of Europe. 

The cutaneous transpiration may be diminished or suspended, 
as is often observed in the first period of acute diseases, in diabetes 
and dropsy, in which the skin is habitually dry. 

However abundant it be, the transpiration may present appre- 
ciable changes in its odor, a circumstance which the physician 
should not omit to notice. The odor of the transpiration is gen- 
erally a little acid ; sometimes, fetid. It has been compared, in 
rubeola and scarlatina, to that of mouldiness ; it is cadavoric in 
some adynamic fevers. 

M. Landre-Beauvais and Dance* have noticed incases of men- 
tal alienation a peculiar odor of the transpiration with which the 
furniture and apartments become durably impregnated, whatever 
be the neatness of the individual. In the miliary sweat, the odor 
exhaled has been compared by some, to that of chlorine, by others, 
to that of rotten straw. 

The odor of mice, supposed by some authors to be one of the 
symptoms which frequently accompany fevers of bad character 
and cerebral affections, arises both from the flowing of the urine 
into the bed of the patient, and the oil cloth placed over the mat- 
trass, the emanations of which, developed by the heat and com- 
bined with those of the urine, produce this peculiar odor. In some 
cases, the odor exhaled by the patient is owing to his food and the 
qualities of the air which he breathes. In persons who eat garlic 
and onions, the cutaneous exhalation is charged with this odor. We 
have had at the hospital a groom, who, during the course of an 
inflammatory bilious fever, continually exhaled a strong odor of 

* Manuel de Semeioiujue. 
17* 



198 SYMPTOMS. 

the stable. We satisfied ourselves that all his clothing was re- 
moved, and that the odor, which was noticed by all who came 
near him, proceeded from the patient himself. 

In the course of acute febrile diseases and some cases of hectic 
fever, the abundant sweating may be accompanied by numerous 
eruptions of vesicles, particularly apparent upon the anterior part 
of the trunk, about the size of a millet seed and filled with a dia- 
phanous fluid, generally more appreciable to the touch than to the 
eye, breaking under the finger, and leaving upon the pulp a sen- 
sation of moisture : these have been called sudamina, from their 
resemblance to drops of sweat. Of all acute diseases in which 
this phenomenon is observed, typhoid fever is that in which 
it most commonly appears, a circumstance not without value in 
the diagnosis of this disease. Abundant sweating is not necessary 
to the reproduction of sudamina, and it is not uncommon to observe 
them in persons who have been free from sweating. 

2. Disorders of the mucous exhalation are more difficult to ap- 
preciate, because the membranes from which they take place are 
inaccessible to view. The alterations, however, which they pre- 
sent at their orifices can be distinguished by the eye, and the 
examination of the excreted matters, may throw light upon the 
changes effected in the mucous exhalation in deep-seated organs, 
as the intestines, bladder, &c. 

In health, the mucus, the consistence and quantity of which 
varies in the different parts of the body where it is exhaled, is 
furnished in such a proportion as, without being sufficiently abun- 
dant to escape, to prevent the adhesion of these membranes, facili- 
tate their movements and the passage and progression of the 
substances taken into their cavities. Its appearance and composi- 
tion varies according to the mucous surface from which it is 
exhaled. Thus that which comes from the neck of the uterus is 
ordinarily clear, transparent, analogous to albumen, without odor, 
always alkaline, and, when viewed with the microscope, appearing 
homogeneous and free from globules (Donne) ; the vaginal mucus, 
on the contrary, is thick, creamy, always acid, and never ropy.* 

In disease, the mucous exhalation may become increased, dimin- 
ished, suspended and variously changed. These changes rarely 
occur simultaneously in all parts of the system. Their successive 
appearance in all these parts is more frequently observed, as in 
some catarrhal affections ; they are most frequently partial. In- 
crease of the mucus exhaled, is noticed in the second period of 
catarrh ; its diminution is sensible at the commencement of this 
affection, and in the course of grave fevers ; the mucous membrane 
of the mouth and nasal fossa3, in these diseases, is often very dry. 

The mucus may become altered in its qualities ; its odor may 
be nauseous, spermatic, and sometimes acid or fetid ; its color 
becomes green or yellow in chronic discharges ; sometimes red in 
dysentery, black in some grave fevers, or it may be Jimpid and 

* Donne, Recherchcs sur les divers mucus. 



SYMPTOMS. 199 

resemble the white of the egg, as in certain cases of bronchorrhoea ; 
in other cases, it may be white and opaque, and it is then often 
impossible to distinguish it from pus. Its consistence becomes 
diminished in the pituatary flux, and in serous diarrhoea, and is 
increased in chronic catarrh ; it assumes, in some cases, a flaky, 
membranous or tubular form, in which it is rejected in shreds. 
The mucus may be excreted alone, as in coryza, angina, and 
blennorrhagia ; it may be mixed with other substances, as urine, 
in cattarrh of the bladder, faecal matters, in dysentery, and ali- 
mentary substances in vomiting. From whatever surface it comes, 
it may be mixed with blood or pus; in the latter case, the purulent 
matters form in the opaque mucus, narrow and irregular streaks 
still more opaque : this is daily noticed in the second stage of 
phthisis, and at an advanced period of vesical catarrh occurring 
in old persons. 

Another remarkable alteration presented by the mucus in disease, 
is the contagious property it acquires in blennorrhagia, and, ac- 
cording to some authors, in many other cattarrhal affections: by 
virtue of this contagious property, it may cause, in a healthy per- 
son, the development of an affection similar to that by which it 
was itself produced. 

3. In health, the serous exhalation should exist in such propor- 
tion, that the membranes and areolae which it is destined to lubri- 
cate, should be always moist, without ever containing fluid. The 
disorders of this exhalation are difficult to appreciate, because the 
organs are inaccessible to view, and there is no excretion whereby 
to judge of the changes which take place. 

Does the diminution or suppressson of the serous exhalation 
ever occur during life, as the works oLMarandcl would lead us to 
suppose 1 This question, which belongs rather to pathological 
anatomy than symptomatology, does not seem to us yet decided. 
We only know that, where two opposite serous surfaces have become 
adherent, all exhalation is necessarily suspended, or so modified as 
no longer to belong to this kind of exhalation. 

The increase of the serous exhalation is easy to distinguish 
when it occupies the cellular tissue (p. 76). This is far from 
being the case when there is an accumulation of this fluid in the 
serous membranes ; it may, however, give rise to phenomena 
which may lead us to suspect it, when in small quantity, and to be 
certain of its existence, when in abundance. The distension of 
the cavity which contains the fluid, the symptoms arising from 
compression of the neighboring organs, and, in some cases, the 
fluctuation and the changes in the resonance of the parts, will 
generally enable us to distinguish the accumulation of serum. 

The changes in the color, consistence and nature of the exhaled 
fluid, are never appreciable during life, unless there be an acciden- 
tal opening in the parietes of the cavity containing it, or artificial 
issue be given to it. This change, consequently, belongs to patho- 
logical anatomy rather than to symptomatology. 

4. The exhalation which occurs in the articular cavities, or in 



200 SYMPTOMS. 

the synovial bursee, furnishes few symptoms. The distension of 
the soft parts, obscure fluctuation, and sometimes, as in the knee, 
the shtfck of the articular surfaces, under the pressure of the hand, 
renders the accumulation of synovia apparent. In some cases 
also, concretions are found in this fluid, which are entirely free and 
felt at intervals in different parts of the joint. 

5. Increase of the exhalation in the eye produces hydropthalmia; 
in the internal ear, it leads to rupture of the tympanum, &c. 

6. We have elsewhere referred to the exhalation of fat in its 
vesicles, and shall not here again recur to it. We shall also pass 
over certain exhalations which are indicated by no sensible phe- 
nomenon, as those which take place upon the internal surface of 
the blood vessels, lymphatics, &c. 

7. To these different kinds of exhalation, that may be added 
which furnishes the digestive tube with the gases necessary to its 
functions, and which presents, in disease, modifications more or less 
remarkable, owing to which the abdomen becomes sometimes very 
voluminous and resonant, and sometimes flattened, and almost 
entirely dull on percussion. These variations in the volume and 
resonance of the abdomen, frequently, rather depend upon some 
obstacle to the circulation of the gases in these viscera, than to 
their too abundant secretion ; but sometimes, particularly in hys- 
terical females, the sudden changes which the abdomen presents, 
without the occurrence of any gaseous emission, can only be 
accounted for by supposing alternations of exhalation and absorp- 
tion of these gases. 

8. Lastly, the sanguineous exhalations, which, in health, period- 
ically make their appearance and concur in maintaining the general 
equilibrium of the functions^may, in disease, be increased, dimin- 
ished, suppressed, or only Inverted. The menstrual exhalation 
frequently presents these various phenomena in the diseases of 
females, and analogous disorders have been many times observed 
in men accustomed to the haemorrhoidal flux or epistaxis, &c. 

But if there are some normal haemorrhages which are connected 
with health, and form a part of its attributes, there are many 
more which only appear under the influence of disease and, in 
some cases, alone suffice to constitute it. 

B. Morbid Exhalations. 

At the head of morbid exhalations, may be mentioned those of 
the blood, or hamorrhages, * and of pus, or pyogenia.f 

1. Haemorrhages consist in the escape of blood from the vessels 
destined to contain it : this flow is sometimes owing to the action 
of a wounding instrument, which, by dividing the vessels in which 
the blood circulates, furnishes the natural explanation of the acci- 
dent produced. But, in many cases, the flow of the blood from 

* Jlipa, blood ; ^cui, I run. 

t Ilvor, pus j yimiiui, I am generated. 



SYMPTOMS. 201 

these canals, occurs independently of any external cause ; the 
haemorrhage takes place, as it were, spontaneously, and is hence 
called spontaneous, in opposition to the preceding, which is called 
traumatic. Among the haemorrhages, called spontaneous, some are 
connected with a material lesion of the part from which the blood 
proceeds, as tubercles, cancer, &e ; these are termed symptomatic. 
Others, epistaxis, for example, occur, without the existence of any 
lesion discoverable during life or by examination after death, to 
account for such a phenomenon : these have been called essential, 
as, being symptomatic of no appreciable affection, they themselves, 
in the present state of the science, represent the disease. These 
essential haemorrhages are by no means the most common ; if we 
except epistaxis and the haemorrhoridal flux, which often relieve 
the wants of the constitution, and which, like the menstrual flow, 
contribute to health, they are, as we shall see in the chapter on 
diagnosis, in most cases, symptomatic ; they are sometimes owing 
to a lesion of the organ from which the blood flows, and of which 
they constitute the first sign; and sometimes to a general affection 
of the economy, the blood, in these cases, often flowing from dif- 
ferent parts, as in scurvy and some pestilential diseases. Spon- 
taneous haemorrhages generally occur from the mucous membranes, 
rarely from old cicatrices or any other point of the cutaneous 
surface ; they sometimes appear in the cellular tissue, where they 
form spots and ecchymoses, to which we have referred above. The 
blood may be also exhaled into the serous and synovial mem- 
branes, into the parenchyma of the viscera, muscles, &c. ; but, in 
such cases, the haemorrhage is often manifested by no certain sign. 
The blood which flows from the body, presents varieties in its 
color, which may be florid red or livid, in its consistence, which 
may be soft or firm, in its quantity, which may vary from a few 
drops to several pounds, and in the substances with which it may 
be mixed. Haemorrhages differ also in respect to the period of the 
disease in which they occur, and the influence they exert upon its 
progress and termination : they have hence been distinguished 
into those that are favorable, prejudicial, or indifferent. 

2. Pyogenia. The opinions of physicians upon the formation 
of pus, have been very various : some, have pretended, with 
Dehaen, that it is formed in the arterial system, to be exhaled in 
the inflamed part; others, that it can only be produced where it is 
found to exist. Among the latter, some have regarded pus as 
proceeding from the broken down parts where the suppuration is 
taking place : others have considered it the result of a chemical 
combination between the various fluids of the affected part, and par- 
ticularly between the lymph and fat. These two opinions, the first 
of which has been for a long time favored in the schools, and the 
second of which has but few followers, are now generally aban- 
doned, and pus is now considered as the result of a morbid 
exhalation from the same organs which produce the natural exha- 
lations. 

A very remarkable phenomenon in the exhalation of pus, is, 



202 SYMPTOMS. 

that it does not present the appearance and consistence peculiar to 
it, till after it has remained for a certain length of time upon the 
organ which furnishes it. Van Swielen remarked that when the 
fluid furnished by a wound was hourly removed with a sponge, 
the fluid thus obtained was not purulent, but a thin and turbid 
serum. 

All the tissues are not equally disposed to the formation of pus ; 
but there is none, with, perhaps, the exception of the tendons, 
cartilages and aponeurosis, in which inflammation may not pro- 
duce suppuration. Inflammation does not always produce pus, but 
it is generally supposed that the latter is never formed unless there 
have been previous inflammation, either in the part where the pus 
exists, or at a greater or less distance from it ; in the latter case, 
the pus may have reached the point it occupies in obedience to the 
laws of gravity (abscess by congestion), or have been displaced by 
the exhalent vessels after having been absorbed in a more or less 
remote part of the economy {metastic abscesses). See Metastasis. 

The displacement of the pus in abscesses by congestion, is a 
phenomenon which has long been known, and upon the production 
of which there has been little diversity of opinion. Pus formed 
slowly at some elevated part of the body, without being circum- 
scribed by previous acute inflammation, may find its way down 
between the meshes of the cellular tissue, and collect at the lowest 
point, in the loins, for example, or in the superior part of the 
thighs, and form a fluctuating tumor at some distance from the 
place where it was produced. In regard to metastatic abscesses, 
they have been of late particularly studied, but their history still 
presents some obscure points. They have been frequently observed 
in variola, in the period of desquamation : they appear, in these 
cases, as brownish, fluctuating tumors, very tender on pressure, 
being formed and discharging themselves with great rapidity, in a 
few days or hours, and from which flows a reddish or sanious 
pus : this fluid, which is doubtless absorbed from the variolic 
pustules, finds its way to the skin, being very rarely deposited in 
the internal parts. It is far otherwise with the abscesses which 
follow wounds, surgical operations, parturition, between which and 
the two first conditions there exists some analogy, and phlebitis 
produced by venesection. In these cases, rigors and ataxic symp- 
toms supervene, followed by the appearance of indolent fluctuating 
tumors in different parts of the body, and sometimes in the sub- 
stance of the muscles, varying in size from that of a nut to that 
of a pullet's egg. In some cases, one or more articulations present 
swelling and fluctuation, with or without pain. Examination 
after death, reveals the existence of pus at all these points, and 
often numerous internal abscesses, scattered through those viscera 
which are the most vascular, as the lungs, liver and spleen ; more 
rarely the brain and kidneys ; and, in many cases, there are evi- 
dent traces of inflammation in some part of the venous system. 
This assemblage of phenomena, has led all physicians to regard 
these abscesses as produced by the passage of pus into the blood, 



SYMPTOMS. 203 

whether the pus formed in the veins be thus carried throughout 
the circulatory system, or be introduced into it by means of lym- 
phatic or venous absorption. But in the attempts to explain the 
formation of these abscesses, there has not been the same unanim- 
ity of opinion ; some have supposed them to be merely depositions 
of pus which has been absorbed ; others have considered that the 
blood, altered by its mixture with pus, becomes, in various parts 
of the economy, the material cause of a suppurative inflammation. 
Neither of these opinions is wholly admissible ; the former, be- 
cause these abscesses are formed not only in open cavities, as the 
meshes of the cellular tissue and synovial membranes, but in the 
parenchyma of the lungs, liver, spleen, brain, kidneys and mus- 
cles, in which a cavity cannot be formed except by means of an 
inflammatory process ; it may be added that the abundance of pus 
found in metastatic abscesses, is often disproportionate to the extent 
of surface where the pus was first formed, and finally, that the 
pus deposited in an organ, itself becomes an agent of suppuration; 
that the pus, as has been said, produces pus. In regard to the 
second opinion, the alteration of the blood by pus, it does not 
account for the rapidity with which these collections form in the 
subcutaneous cellular tissue, often without the existence of pain. 
It might also be asked, how a general cause can produce circum- 
scribed, though multiple, results. It may then be admitted, from 
observation, that the pus carried into the circulation, is deposited 
in various quantities, in different parts of the economy, so as indi- 
rectly to form, in one part, an abscess, and in another, become the 
material cause of a suppurative inflammation. In regard to the 
causes, by virtue of which, pus that has been absorbed, is depos- 
ited in some parts rather than others, and in various quantities, 
they are in the present state of the science entirely unknown : the 
artificial irritations established by the physician upon the skin, by 
means of topical rubefaciants or vesicants, are not here called 
purulent collections, and seem to have no influence upon the 
unequal and inexplicable distribution of this deleterious fluid in 
the various parts of the body. 

The softening of tubercles is a phenomenon which appears op- 
posed to the opinion above expressed, viz., that the presence of pus 
is a sign of previous inflammation. A body, to all appearance 
unorganized, is formed in the tissue of the lungs or some other 
organ ; it acquires a certain size, and is then found to present an 
opaque color, moderate hardness and great friability. At the 
end of a certain time it becomes softened sometimes throughout its 
whole extent, sometimes at its centre, and is converted into a mat- 
ter analogous to the pus exhaled by an -inflamed organ ; but si- 
multaneously with the occurrence of this change, redness, swelling 
and heat supervene in the surrounding parts, as in the case of sub- 
cutaneous tubercles ; and hence it is natural to suppose that the 
inflammation of the neighboring parts is not foreign to the trans- 
formation of the tuberculous matter into pus. 

The pus exhaled upon the surface of the skin, or external 



204 SYMPTOMS. 

wounds, escapes freely. That formed internally sometimes extends 
throughout the tissue of an organ, as is observed in the lungs, and 
sometimes forms one or more collections termed abscesses. The 
pus collected into an abscess ordinarily finds its way towards the 
integuments or the canals through which it may be discharged 
from the body, by the gradual absorption of the intervening parts. 
Pus which extends throughout the tissue of an organ cannot be 
evacuated in this way, and absorption is the only means by which 
it can be removed. This absorption is manifest in some subcu- 
taneous abscesses, particularly in buboes; such inflammatory 
tumors after being soft and fluctuating, in a few days, and even a 
few hours, may gradually flatten, and the fluctuation disappear. 

Pus, considered in itself, presents varieties relative to its physical 
and chemical properties, and its action upon the animal economy. 

Its quantity is relative to the extent of the suppurating surface, 
the period of the disease and many other circumstances. It may 
be diminished by errors in diet, violent mental emotions, a febrile 
recrudescence which should always lead us to fear a complica- 
tion or purulent absorption, or any other supervening evacua- 
tion. Hatter observed that the exhalation of this fluid was gen- 
erally more abundant in the night than during the day. 

The color of pus is ordinarily yellowish white, or greenish ; 
it is sometimes reddish or livid; it has been noticed to be bright 
yellow in persons affected with jaundice. Its color is sometimes 
uniform throughout, sometimes diversified; in some cases it is 
thick, homogeneous, and its globules, when examined with the 
microscope, very abundant ; this is called laudable or healthy pus; 
it is observed in cases of healthy inflammation running a rapid 
course, and occurring in persons of good constitution. In other 
cases, it is clear and mixed with opaque flocculi ; it sometimes re- 
sembles badly clarified whey, as is observed in chronic abscesses 
which occur in scrofulous persons and those of bad constitution. 
Sometimes serous or sanious pus becomes of a brownish color by 
the contact of the air ; it blackens silver and lead instruments with 
which it comes in contact; this has been attributed to the sulphur- 
retted hydrogen gas contained in it. Some abscesses of the liver 
furnish a thick, reddish matter, resembling the lees of wine, 
which deposits, on standing, portions of the substance of the liver. 
Surgeons, and Boyer in particular, did not admit that any other 
than that presenting these conditions, proceeds from the liver, but 
it is now proved that a phlegmonous pus has been found to exist 
in this viscus, several examples of which have been published by 
M. Louis, as occurring at La Charite and observed by us together. 

The odor of pus is ordinarily nauseous, sometimes character- 
ized by a penetrating, nauseous or insupportable fetor. It has been 
long observed by surgeons that pus contained in an abscess of the 
abdominal parietes, or at the margin of the anus, often exhales the 
most fetid odor, analogous to that of the faecal matters, so as to 
lead to the suspicion of a communication between the abscess 
and intestines. Abscesses of the mouth and pharynx also yield a 



SYMPTOMS. 205 

very fetid pus. Every one is familiar with the repulsive odor that 
pus acquires in ahscesses of the labia majora in females, and in 
urinal abscesses of both sexes. This fetor is not generally ap- 
parent at the time the abscess is opened, except in those cases in 
which it exists at the surface of the skin, or in the neighborhood 
of organs which contain air. It may acquire this odor after the 
abscess is opened, if air be admitted into the cavity. The taste 
of pus, according to Schcvilgue, is nauseous and sometimes acrid : 
its specific gravity is greater than that of distilled water. The 
same causes which influence its quantity ordinarily modify its 
other physical qualities, and particularly its consistence and color. 
The chemical properties of pus, being of no practical value, we 
shall not here consider. 

The action of pus upon the economy deserves particular atten- 
tion ; this varies according to the tissues. Upon the skin, pus 
causes only redness and excoriation ; in the cellular tissue, through 
which it flows, it excites the formation of new pus ; in the vicinity 
of bones, it wears them away by exciting in their tissue interstitial 
absorption. If it exist in circumscribed abscess, and come in con- 
tact with the air, it soon acquires a strong odor, loses its homoge- 
neousness, and produces general functional disturbance and death. 
The same phenomenon occurs whenever the pus, without being 
altered, is accumulated in one of the splanchnic cavities, or one of 
the viscera important to life. We have above referred to the me- 
tastatic phenomena which may result from its absorption. Finally, 
this fluid may, in some diseases, become the vehicle of contagion, 
as is observed in variola, syphilis and glanders. 

The distinction between mucus and pus is one of the points which 
most occupied the attention of physicians of the last century. 
They supposed that pus was constantly the result of a solution of 
continuity, and never owing to simple exhalation; in order to re- 
tain the name of pus for certain fluids which presented all its 
characteristics, they were also obliged to suppose ulcerations where 
they did not exist ; they supposed their existence in the urethra 
and uterus when affected with catarrh. The chemical experi- 
ments, which have been made, in order to determine the true 
characteristics of pus, have terminated in nothing satisfactory. 
The results of microscopical researches, have been equally unsuc- 
cessful. It was thought for a long time that when globules, simi- 
lar to those observed in the blood, were noticed in the secretion of 
a mucous membrane, they indicated the presence of pus. But it 
is now proved that mucus varies much in its physical and chemi- 
cal composition, and that it often contains globules, which, in 
their form and volume, resemble those of pus. Chemical reagents 
and the miscroscope are useless when the appearances presented 
by pus and mucus are distinct; they are also insufficient, when 
these two fluids resemble each other. 

3. There are still other essentially morbid exhalations which 
need only to be enumerated ; such are those occurring between the 
reticular tissue of the skin and epidermis, in pemphigus and all 
18 



206 



SYMPTOMS. 



the vesicular and pustular eruptions. These fluids, in coagulating 
and hardening by exposure to the air, form, upon the surface of 
the skin, peculiar concretions, to which the term crusts or scabs 
has been applied. Their study is not without importance in cutane- 
ous pathology ; for by considering their form, surface, degree of 
prominence or depression, color, hardness, degree of adherence, 
etc., we are enabled to determine the kind of cutaneous disease 
without having seen it in its elementary form. It is thus that 
porri go favosa is distinguished, its crusts being yellowish and pre- 
senting a cuplike depression ; these crusts are yellow, thick and fria- 
ble in impetigo; they are very adherent, thick, blackish and 
elevated in the centre, in ecthyma; while in vesicular and bulbous 
affections, they are thin, easily detached, and of a yellowish or 
brownish color. 

The skin may be also the seat of another morbid exhalation, to 
which the term squamous has been applied, and which is charac- 
terized by the formation, upon the diseased surface, of an inorganic, 
lamellar substance of a grayish white color, dry, friable, more or 
less thick and adherent, and which is regarded as a morbid secre- 
tion of the epidermis. Scales are observed in lepra, psoriasis, 
pityriasis and icthyosis. 

C. Artificial Exhalations. 

Artificial exhalations are, in relation to symptomatology, of less 
importance than all others. It may, however, be well for the phy- 
sician to know the quantity and quality of the pus furnished by 
cauterization, vesication, moxas and setons ; the aspect of the ex- 
halent surface also deserves special attention. 

In diseases, in which the strength is maintained, the pus of 
artificial ulcers is in a certain quantity, of a proper consistence, 
homogeneous, and its odor is not repulsive ; the surface from which 
it proceeds is of a rosy or red color, and acutely sensitive without 
being morbidly so. In diseases which tend to a fatal termination, 
the pus is almost always serous or of unequal consistence, it is 
sometimes mixed with blood and often emits a very fetid odor ; 
the exhalent surface is pale or livid, sometimes ecchymozed or 
black; it is sometimes insensible, and sometimes the least touch 
excites in it severe pain. When artificial ulcers exist before the 
disease, it often happens that they become dry a few days previous 
to its development, or the matter exhaled may present remarkable 
changes. 

§ II. Secretions properly so called. 

In health, the secretions concur, together with the exhalations, in 
maintaining the general equilibrium ; the first increasing when the 
second diminish, and vice versa. In disease, this order, sometimes 
preserved, is often interrupted, and cases occur where both are 
simultaneously increased or diminished. In the cases of hectic 



SYMPTOMS. 207 

fever that fell under the observation of Cotugno at Naples, there 
were, at the same time, continual perspiration, laxity of the bowels, 
and a copious flow of urine. In the first and second stage of 
many acute diseases, the secretions and exhalations are simultane- 
ously suspended ; the skin is dry, the abdomen contracted', and the 
urine is excreted in small quantities. 

Independently, however, of this general disturbance, the particu- 
lar secretions are subject to changes, which we proceed to enume- 
rate. 

1. The tears in health are secreted in such proportion, that 
while the eyes and eyelids are constantly moistened, none of the 
fluid flows out over the cheeks. Under certain circumstances, as, 
the existence of vivid mental emotions, the exposure of the face to 
cold winds, etc., the tears are secreted in greater abundance, filling 
the eyes, and even escaping upon the face. In disease, the secre- 
tion of the tears is seldom diminished; it is increased, in the first 
stage of eruptive fevers, particularly rubeola, in the decline of the 
paroxysm in hysteria, and in some forms of monomania. The 
tears are also more abundant in many diseases of the eyes, and 
particularly ophthalmia. During the existence of tic douleureux 
in the ophthalmic branch of the fifth pair, the secretion of the 
tears is increased, and they often produce a sensation of warmth 
or burning in the parts with which they come in contact.* In 
some cases, the tears appears to be altered in their nature, becom- 
ing more acrid, to judge from the effect which they produce 
upon the skin of the face, over which their passage is indicated by 
redness and excoriation. 

The fluid secreted by the follicles of Meibomius sometimes 
forms a kind of gummy concretion, (chassie), which has the effect 
of producing adhesion of the eyelashes and consequently the free 
edges of the eyelids. This alteration of the secretion occurs in 
most cases of ophthalmia, particularly the ophthalmia of children, 
and in the inflammation of the eyelids such as results from an 
extension of erysipelas of the face. Lastly, the eyes often become 
thus affected at the close of acute diseases which terminate unfa- 
vorably. 

2. The secretion of the saliva in health is abundant during 
meals, but diminishes, and its excretion almost entirely ceases, in 
the intervals, unless excited by the imagination, or by mastication, 
etc. In disease, the secretion of the saliva is sometimes increased 
to a considerable degree, either in consequence of the disease itself, 
or the remedies employed for its cure, as the different mercurial 
preparations. This increase is termed salivation or ptyalisnvf 
(salivalio, ptyalismus), and is generally accompanied by swelling 
of the gums, cheeks, tongue, and more rarely, the parotid region. 

* The flow of tears over the cheeks does not. always indicate an increased se- 
cretion. The inertia of the punctaand lachrymal canals, the eversion of the lower 
eyelid, the obstruction of the lychrymal sac or nasal canal, and certain diseases of 
the eyelids, may also produce epiphora. 

t IIvv<xXiauac, from jirvw, 1 spit. 



208 SYMPTOMS. 

Salivation has been attributed to an increased secretion in the sali- 
vary glands (parotid, submaxillary, sublingual) produced by the 
elective action of mercury upon these glands ; but more exact ob- 
servation having proved the existence of considerable swelling of 
the mucous membrane of the mouth, unaccompanied often by any 
swelling of the salivary glands, we should refer the increased 
secretion of which the mouth is the seat, chiefly to its lining 
membrane, and the numerous follicles with which its surface 
is covered, according but a secondary influence, in the phenomenon 
of salivation, to the salivary glands, properly so called. The sali- 
vary secretion is also increased in inflammations of the throat, in 
cases of apthse, ulcerations and glossitis, and during dentition 
which, according to most authors, it facilitates. Sydenham laid 
great stress on ptyalism occurring in variola of adults, commencing 
generally with the eruption and terminating towards the twelfth 
day. Its termination before this period, he considered an unfavor- 
able omen. If we consider, however, that this salivation is often 
owing to an eruption of variolic pustules in the mouth, we shall 
attach less importance to the phenomenon pointed out by Syden- 
ham. 

The secretion of saliva is diminished in most acute diseases, in 
which the mouth is constantly dry. It appears to undergo a 
change in many cases of neurosis, in which it becomes acrid and 
burning; in some diseases of the bladder, in which it has a urinous 
taste ; and in hydrophobia, in which it seems to acquire contagious 
properties. Its excretion becomes difficult or impossible in cases 
of obstruction or obliteration of the excretory ducts. It may 
escape externally in cases of wounds or fistula of the ducts or 
glands themselves. 

The principal chemical modification which the saliva undergoes 
is the passage from an alkaline to an acid state. This acidity has 
been observed by M. Donne, to acccompany, most generally, an 
irritated or inflammatory state of the stomach, either primary or 
secondary, and he thought might serve to establish the diagnosis 
of some gastric affections. But the researches of other physicians 
on this point have not confirmed the results published by M. Donne, 
and renewed examination will be necessary to remove this uncer- 
tainty. The permanent acidity of the saliva seems, as some au- 
thors have remarked, to exert an influence on the development of 
dental caries. Lastly, the acidity of the saliva is one of the most 
common causes of acidity of the breath, which has been before 
considered (page 137), and which deserves the particular attention 
of the physician. 

3. The secretion and excretion after bile, occur in health without 
any apparent phenomenon, the situation of the biliary organs not 
permitting us to observe the changes they may present. It is 
nearly the same in cases of disease ; necropsies frequently bring to 
light lesions in this fluid itself, and in the disposition of its excre- 
tory ducts, which had not been suspected in life. Even at the 
present day, we have but a very imperfect knowledge of the dif- 



SYMPTOMS. 209 

ferent modifications which health and disease may effect in the 
composition of the bile. In fact, if we consult all the works on 
pathology published since the time of Galen, and particularly dur- 
ing the last two or three centuries, we shall find that the physi- 
cians of this long period, have described a multitude of changes in 
the bile, by the aid of which they have explained the nature of 
many diseases and the forms under which they are presented; but 
this doctrine, connected with the humoral ideas then entertained, 
was supported by no positive proof. 

The bile in its normal state, i? liquid, of a yellow or greenish color, 
viscous, ropy, bitter and slightly alkaline. It may present different 
degrees of consistence or color, without our being able to determine 
how far these modifications are consistent with health. The bile 
is often changed, either in quantity or quality, in many diseases 
of which the biliary apparatus is not the principal seat ; while in 
many deep-seated, though partial affections of the liver, as cancer 
and abscess, the bile undergoes apparently no remarkable change, 
this organ preserving its normal texture in those portions of its 
parenchyma which lie between the cancerous parts, or the puru- 
lent collections. 

M. Louis has satisfactorily established that alterations in the 
bile and the gall-bladder are much more frequent in the course of 
the typhoid affection, than in the other acute diseases ; and that of 
all the chronic affections, pulmonary phthisis is that in which the 
bile most frequently undergoes change, in such cases, closely re- 
sembling treacle. M. Andral has noticed in the same affection, 
that the bile is sometimes replaced by a fatty fluid. In atrophy of 
the liver, and especially in cyrrhosis, the bile generally exists in 
small quantity and is sometimes almost colorless and albuminous. 
M. Hermann, of Moscow, is confident that in Asiatic cholera the 
bile contains a very large proportion of resinous matter. This 
fluid may acquire irritating and even poisonous properties, as has 
been proved by the experiments of Deidier * on the bile of persons 
affected with the plague at Marseilles in 1720, and by Vicq 
d'Azir, f in an epizooty which he observed in 1778. We are still 
entirely ignorant whether an alteration in the bile is connected in 
any way with those diseases of warm countries, described under 
the name of bilious fevers, or with certain sporadic choleras. 
English physicians are of opinion that a great number of the de- 
rangements of the digestive organs, are connected with some 
change in the composition of the bile; but nothing is with cer- 
tainty known upon this subject. 

A greater part of the alterations in the bile of which we have 
just spoken, have only been verified after death by examination of 
the fluid collected in the gall-bladder; they consequently belong to 
pathological anatomy, rather than to symptomatology. Never- 
theless, we have thought it best to enumerate in this connection 

* Expir. sur la Bile, Zurich, 17-22. 

f Moyens Cur. Contre les Malad., Pestil, p 94. 

18* 



210 SYMPTOMS. 

the changes noticed in autopsies in the composition of the bile, in 
order to direct the attention of observers to the examination of the 
fluid excreted, either by vomiting, or by stools, in the course of 
diseases. We should hope that accurate observations of the bile, 
especially when vomited in an almost pure state and in considera- 
ble quantities, will furnish interesting results, and throw much 
light, in many cases, on diagnosis. We are equally persuaded 
that the chemical analysis of bilious stools and other stercoral 
matters, will one day furnish signs of great value in the diagnosis 
of diseases of the liver, the intestines and all the other digestive 
organs. 

The only changes hitherto noticed in the biliary secretion and 
excretion, have reference either to its increase in bilious flux, or 
to its suppression in cases of jaundice arising from occlusion of the 
excretory ducts by calculi contained within them, or by the com- 
pression of a tumor. Whenever any cause obstructs the excre- 
tion of the bile, the alvine matter loses its natural color, and 
becomes of a grayish tint ; while the fluids excreted, and particu- 
larly the urine, assume the color of the bile, which also diffuses 
itself over the whole skin, and exists to a considerable extent in 
all the solids. Chemical analysis discovers in the urine, in the 
serum of the blood, and in most of the humors of these subjects, 
some of the materials that enter into the composition of the bile, 
such as the coloring matter and perhaps the picromel. The yellow 
color, so remarkable after death in all parts of the body, proves 
also, that all the organs, cartilages, tendons and even bones, par- 
ticipate in the general impregnation. 

4. But however obscure the changes that take place in the secre- 
tion of the bile, those that disease produces in the secretion of the 
pancreatic fluid are still more so. Is there any increase of this 
secretion in certain aqueous fluxes of the intestines, in serous 
diarrhoea, for example I Does the ptyalism that takes place in 
certain abdominal affections indicate, as has been asserted, that 
the secretion of the pancreatic fluid is diminished or suppressed 1 
May not the formation of calculi in the pancreatic duct, give rise 
to accidents analogous to those observed in hepatic and nephritic 
colics'? In the present state of the science it is impossible to an- 
swer these questions. 

5. The secretion of the urine is one of the most important, both 
on account of its quantity and because its changes are readily 
appreciated. In health, the quantity of the urine is about the 
same every day, though its increase or diminution depends upon 
the abundance of the other excretions, upon the quantity of food 
and drink, and upon changes of temperature. At the time of its 
excretion, the urine is warm, transparent, of a pale yellow color, 
and slightly acid. It has an odor peculiar to itself unaccompa- 
nied with fetidness. It is salt and bitter to the taste, and has a 
specific gravity of 1.018. It often becomes turbid upon cooling, 
recovering its transparency after its floating particles are precipita- 
ted. After two or three days it becomes ammoniacal and fetid. 



SYMPTOMS. 211 

The urine of the healthy man presents numerous changes in its 
physical and chemical properties, according as it is secreted before, 
during, or after, meals, and particularly according to the quantity 
and nature of the food and drinks. Certain substances change, in 
a remarkable manner, its color and its odor; it becomes blackish 
after the simultaneous use of rhubarb and iron, cassia and the 
chalybeates; sorrel broth, and the root of the strawberry and 
madder, change its color to red ; turpentine gives it the smell of the 
violet, and asparagus, an intolerable fetor. 

In disease, the excretion of this urine and this fluid itself undergo 
important changes. 

The excretion of the urine may be attended with pain, as in 
blennorrhagia ; dysuria* is where it is attended with difficul- 
ty, as in the contraction of the canal of the urethra ; stran- 
gury (stranguria) f where it flows guttatim, a symptom which 
frequently accompanies vesical catarrh; ischuria% or the reten- 
tion of the urine, is where its excretion is impossible ; and vesi- 
cal tenesmus, where there is a continual and painful desire to 
make water, and where the urine is excreted in small quantities 
at a time and with a sensation of burning. The excretion some- 
times occurs involuntarily, as in certain spasmodic affections of the 
bladder, in which it takes place at the moment of the desire, and 
in spite of the efforts of the patient to prevent it. In other cases 
in which the excretion of the urine is involuntary, the patient is 
unconscious of it, as in many diseases accompanied with delirium. 
There are other cases in which, instead of being excreted at cer- 
tain intervals and in a certain quantity, the urine flows drop by 
drop without interruption ; this is called incontinence of urine. 
Ordinarily, the urine is only excreted in this manner when the 
bladder has acquired all the distension of which it is capable, 
and its excretion is then said to take place by regorgement. In 
another class of cases the urine flows interruptedly in jets, and its 
excretions ceases and recommences many times before being com- 
plete ; this symptom often arises from the presence of calculi or 
clots of blood in the bladder, which at intervals obstruct the neck 
of this viscus; it is also of frequent occurrence in certain spas- 
modic affections. The excretion of the urine is also subject, in 
disease, to deviations. We have known it in perviousness of the 
urachtts, to escape at the navel, and, in the different forms of vesi- 
cal or urethral perforation, to find its way out through the anus, 
the scrotum and the neighboring parts, and the vulva. Some 
authors have mentioned still more remarkable deviations of the 
urine, such as urinous salivation, perspiration and vomiting. 
Boerhaave thought he even discovered urine in the cerebral ventri- 
cles. These last statements, however, can hardly be received 
with implicit confidence. It may be that the fluids of which these 
authors speak, have had the urinous odor and color, but we may 

* JvciovQta; Svs, witli difficulty ; ovoov, urine, 
t SrQuyyovQia; mouyl, drop ; ovoov, urine. 
J'/a/ui, 1 retain; ovqov, urine. 



212 'symptoms. 

well doubt whether this phenomenon is owing to the actual pres- 
ence of urine. 

The urine, considered in itself, presents numerous changes in 
sickness. These changes relate to its quantity and its physical 
and chemical properties. The quantity of the urine increases 
sometimes in the decline of diseases. It is unusually great in dia- 
betes, and diminishes in dropsy. Entire suppression of the urine 
never takes place, except in cases of occlusion of both the ureters 
simultaneously, or of one only ; and in cases in which, either ow- 
ing to congenital formation, or to complete atrophy of one of these 
organs, but one kidney exists.* In a greater part of the nervous 
affections, the urine is colorless, less acid and often neutral. It is 
generally red and unusually acid at the commencement of acute 
diseases, and brown, or black, in many fatal diseases. The latter 
color generally arises from the coloring matters of the blood con- 
tained in the urine. It may also be owing, according to some 
chemists, to the accidental presence in the urine, of a peculiar acid, 
called rnelanic. Lastly, the urine may become milky white in 
cases in which it contains either pus, or a fatty substance, that can 
easily be separated. But whatever its color, the urine may be 
transparent or turbid. The urine is said to be transparent when 
it preserves its translucency, or recovers it after momentarily los- 
ing it in cooling. Turbid urine is that which remains so, and 
does not become transparent by the precipitation of the particles 
suspended in it. Opacity of the urine is caused by the presence of 
mucus, blood, albumen, pus, etc., but more generally by an excess 
of uric acid, urate of ammonia, or of the alkaline phospates. The 
ancients termed the urine jum,enteuse f when it is turbid and con- 
tains at the same time corpuscules or opaque particles floating in 
it. This expression, however, though much used by old writers, 
has no very definite meaning, and may be applied to urine differ- 
ing very much in chemical properties. The smell of the urine 
becomes ammoniacal in chronic catarrh of the bladder. In certain 
adynamic diseases, and in many vesical affections it emits a 
brackish smell. The discolored urine excreted during the declen- 
sion of hysterical attacks, and in the first stage of intermittent 
fevers in almost inodorous. In inflammatory diseases, on the con- 
trary, it emits a very powerful odor. In diabetes mellitus the 
urine acquires after fermentation an alcoholic smell. In Bright's 
disease, it has sometimes the smell of boiled beef. This latter 
smell is occasionally perceived in the urine of healthy persons, 
especially after profuse perspiration. In many acute diseases, the 
urine differs from day to day with regard to its color, transparency, 
sediments, etc. ; this is termed variable urine. In certain gangren- 
ous inflammations the urine is almost cold at the moment of excre- 
tion. A diminution of its temperature has also been noticed in the 
cold stage of intermittent fever. 

* Vid. our Treatise on Nephritis, Archiv. Gen. de Med. v. 1, 3d Ser. pp. 5 
and 477. 

■(■ Jumentum, beast of burden ; urine that resembles that of mules, horses, etc. 



SYMPTOMS. 213 

Little is known of the taste of urine in a state of disease, on ac- 
count of the natural repugnance to experiments of this nature. 
We know, however, that in diabetes mellitus it has a sweet taste, 
and that it is almost insipid after the hysterical paroxysm. 

M. Rayer, has made numerous experiments upon the specific 
gravity of the urine, which varies, in health, according as it has 
been secreted after fasting, during or after meals, etc. He fixed 
the mean specific gravity of the urine excreted at the hour of wak- 
ing in the morning,* at 1.018, that of water being 1.000. The 
same physician found that in diabetes mellitus, the density of the 
urine is much more considerable, while it is less in diabetes insip- 
idus. In Bright's disease, except in the first or acute stage, it is 
generally lower than in health. The specific gravity of the urine 
may be a circumstance of practical advantage in diabetes mellitus. 
Examined at different hours of the day before and after meals, it 
may indicate the increase or diminution of the sugar. 

The elements of the urine undergo variation in disease to a 
greater or less extent. Thus, the quantity of water may become 
very great, as in diabetes insipidus ; in some nervous affections the 
urine is almost entirely aqueous. The other elements of the urine 
increase, on the contrary, in proportion, in most febrile diseases. 
The quantity of urea rarely increases in sickness, although it is 
very common, as M. Rayer has remarked to find it existing in a 
less proportion, which arises, perhaps, as much from abstinence 
from food, as from the influence exerted by disease itself on the 
renal secretion. It has not yet been proved that the quantity of 
urea is diminished in diseases of the liver ; but in the granular 
affection of the kidneys its diminution is an almost invariable phe- 
nomenon. The uric acid, which enters into the composition of the 
urine in the proportion a thousandth in health, may increase in a 
remarkable manner; this has been particularly observed during 
the progress of rheumatic and gouty affections, and many inflam- 
matory diseases, etc. This excess of uric acid often has the effect 
of producing red gravel in different parts of the urinary passages. 
This acid is generally found in combination with lime, soda, and 
particularly ammonia. There may also be a disproportion of 
phosphoric acid and the phosphates of lime and magnesia in the 
urine, which we notice in cases of rachitis, molhties ossium, and 
in some kinds of gravel ; in all these cases the urine is more or less 
turbid. The salts of soda, potash, and ammonia, are sometimes 
found in more considerable quantities, and render the urine either 
neutral or alkaline. The alkalinity of the urine has also been 
ascertained in phosphatic gravel, in certain cases of Bright's disease 
and frequently in chronic nephritis, as in cases of old men enfeebled 
by privation and misery. It has been stated that alkalinity of the 
urine is frequent in the course of typhoid fevers. M. Rayer as- 
serted that out of fifty cases he formed the urine alkaline but twice, 
and for the space of three days only, and the observations of M. 

* Maladies des Reins, t. 1, p. 71. 



214 SYMPTOMS. 

Rostan agree on this point with those of M. Rayer. Brodie and 
Hunkel have remarked the alkalinity of the urine after traumatic 
or other lesions of the vertebral column ; but as this has been con- 
tradicted, further observation will be necessary to determine it. 

Mucus, which is one of the natural ingredients of the urine, may 
become developed in unusual quantities. We observe this in some 
inflammations of the bladder, in inflammations of the pelvis of 
the kidneys, and of the ureters. 

The urine may also become changed by the presence of different 
substances foreign to its normal composition. Thus, sulphur has 
been found in it, and rare cases are mentioned of phosphorescent 
urine which shines in the dark at the moment of its emission. We 
shall not here refer to the hippuric, oxalic, benzoic, carbonic, buty- 
ric and prussic, xanthic and cystic, acids which have been acci- 
dentally discovered in the urine under the influence of various and 
often inappreciable causes. But there are other substances which 
we find more commonly in the urine, whose existence in it is easy 
to prove and which furnish signs too important to be omitted ; such 
are, blood, albumen, sugar, pus, semen, fecal matters, gas, intesti- 
nal worms, gravel, and many other foreign bodies. 

The urine sometimes contains blood which may come from the 
different parts of the urinary passages. It varies in quantity, and 
is more or less thoroughly mixed with the urine; sometimes is in 
a fluid state, and sometimes exists in the form of blackish clots. 
Occasionally it is discharged in the form of full or tubulous fila- 
ments, which have been mistaken for worms. This clotted form 
indicates the coagulation of blood in the urethra previously effused 
in the kidney itself. Bloody urine, when left to repose, forms 
a blackish sediment composed of bloody globules and fibrine. 
The quantity of the blood is sometimes so small that we can 
ascertain the existence of the globules only by the aid of the 
microscope. The presence of blood in the urine is almost al- 
ways an indication of a cancerous or calculous affection of some 
part of the urinary passages, and particularly the kidneys or blad- 
der; it has been also observed in scurvy, in severe cases of variola, 
and in pestilential diseases. 

The urine may contain albumen in a greater or less quantity, 
the presence of which we can ascertain by the application of heat 
or nitric acid, which produce a white and rlocculent precipitate. 
The presence of a very great quantity of albumen in the urine, 
together with a perceptible diminution of its specific gravity and 
of the proportion of urea and of the salts which it contains, con- 
stitutes the most important sign of that species of dropsy connected 
with disease of the kidneys, first described by Dr. Bright. The 
urine is also albuminous, but generally to a much less degree, in 
the dropsy that succeeds scarlatina and the decline of certain 
acute diseases, as Dr. Martin Solon has proved. The urine may 
contain at the same time albumen, blood and pus in grave affec- 
tions of the urinary organs and in some diseases of the prostate. 

The opinion was for a long time entertained, and even recently, 



SYMPTOMS. 215 

by men of great merit, that the urine of nursing women or of 
women soon after parturition, may contain milk. These opin- 
ions, however, were founded upon no exact observation or experi- 
ment, and there is reason to suspect that the physicians and 
chemists that entertained them, were deceived by the turbid 
appearance of the fluid, by the presence of foreign matter, and 
particularly pus or a fatty substance. Authors, and especially 
Prout, have spoken of chylous urine, that is to say, urine contain- 
ing the organic principles of chyle, visible with the aid of the 
microscope; but the characters of this kind of urine are not yet 
clearly ascertained, and besides, the chylous appearance may be 
owing to the presence of a fatty matter in the urine. Ancient 
writers mentioned the existence of fat or oil in the urine, during 
the course of chronic diseases with progressive emaciation ; but this 
assertion has not been verified, and M. Rayer sought in vain for 
these substances in the urine of phthisical patients. 

Sugar is also found to exist in the urine. This has not only 
been proved by the taste, but has been verified by chemists in a 
more satisfactory manner, by the spontaneous fermentation of the 
urine and by the actual separation of the sugar from its other ele- 
ments. The presence of sugar in the urine is a pathognomonic 
sign of that species of diabetes termed mellitus. This urine has 
a specific gravity greater than that of the healthy individual, 
although it contains less urea and less salts. 

Urine containing pus presents, even at the moment of its emis- 
sion, a turbid and milky appearance. Left in a quiescent state it 
becomes transparent, and an opaque deposit collects in its lower 
part, forming a stratum varying in thickness. This urine decom- 
poses rapidly and becomes alkaline. Pus is generally readily dis- 
tinguished by its qualities where it exists in the urine in any 
considerable quantity ; but when its proportion is small, and when 
mingled with mucus and salts, its presence is very difficult to 
prove. Chemical and microscopic examination may be resorted 
to under such circumstances, with advantage, but in the pres- 
ent state of the science, as we have before remarked, it cannot inspire 
entire confidence. The ascertained presence of pus in the urine 
is always an alarming symptom in prognosis, and very important 
in diagnosis. It is a certain sign either of inflammation of the 
kidneys or bladder, or of an abscess formed near the urinary 
organs and opening into their cavity. Examination of the symp- 
toms preceding the emission of purulent urine and of the organs 
themselves, enable us frequently to discover the parts in which the 
pus has been formed. 

In the course of blennorrhagia the urine sometimes acquires con- 
tagious properties, doubtless owing to the particles of urethral 
mucus which it carries away with it. Mertens, Astruc and Chaus- 
sier, have seen individuals that have contracted a blennorrhagic 
ophthalmia in consequence of bathing the eyes with urine in the 
course of urethritis. 

The urine sometimes contains, also, small solid concretions, 



216 SYMPTOMS. 

some of which are as fine as sand, while others are somewhat 
larger and equalling grains of hemp seed in size. The first kind is 
excreted by the patient unconsciously. The second indicates its 
passage through the canal of the urethra by pain more or less 
acute, and sometimes by a sensation of tearing, according as the 
surface of these particles is smooth or rough, and according as their 
bulk is greater or less. In somes cases their expulsion is attended 
with no pain, and the patient is only conscious of their existence 
from the noise of their fall into the vessel that receives them. 
These concretions are generally formed in the kidneys, and their 
presence in the urine should always lead us to fear that they 
actually exist in the kidneys, and that others are in process of for- 
mation. In some rare instances these concretions are convex on 
one side and concave on the other, and represent a portion of the 
external layer of a calculus which has exfoliated in the bladder, 
and are pathognomic of its presence. 

The saline concretions which form in the urinary passages vary 
considerably in regard to physical and chemical properties. The 
smallest of them, those that do not exceed a pea in size, are termed 
gravel ; all of greater bulk than this are called calculi. Their 
number is more or less considerable, and is, generally, in inverse 
ratio to their volume. They are round, oval or irregular in form, 
sometimes presenting a rough surface (calculs muraux). Their 
surface often presents one or more faces, an almost certain indica- 
tion of the simultaneous existence of several stones in some part 
of the urinary passages. There are cases of gravel or calculi 
that break with the least pressure, while others have the resistance 
and firmness of the hardest stone. A greater part of the urinary 
concretions are formed of uric acid, and are then of a red color 
bordering more or less upon yellow. Next in order of frequency 
are calculi of the amnion iaco-magnesian phosphate, crystal ized 
into prisms and of a whitish color. After these come calculi of 
the oxalate of lime which are black, brown or grayish ; after 
these, calculi of the phosphate of lime and magnesia ; and lastly, 
M. Magendie has described a hairy gravel, of which he gives three 
instances ; in these cases, hairs had formed upon the surface of the 
saline concretions, probably proceeding from some cyst opening 
into some of the urinary passages. 

There have also been discovered in the urine masses of tuber- 
culous and encephaloid matter coming from the kidneys, and fur- 
nishing in some cases very important diagnostic signs. 

In cases of seminal loss, of urethral strictures and diseases of 
the prostate and of the ejaculatory ducts, the semen may flow back 
into the bladder, and be excreted, mingled with urine. From the 
experiments of M. Orfila, it appears that the urine excreted imme- 
diately, or some hours, after a pollution or an ejaculation, carries 
with it, and consequently contains, spermatozoa which had re- 
mained in the canal of the urethra. However few in number 
they may be, they always sink to the bottom of the vessel, and 
can be readily distinguished with the microscope. 



SYMPTOMS. 217 

In cases in which there is a communication between the urinary- 
passages and the rectum, or a portion of an intestine, the urine 
may contain fecal matters, gas may escape through the urethra, 
and worms may also be expelled in the same manner. We may 
also explain in the same way the existence of foreign bodies in the 
bladder, such as pins, fruit seeds, &c., which have been known to 
form the nuclei of vesical calculi. Sometimes too, foreign bodies 
find their way into the urinary passages through an external 
wound, or are introduced by the urethra. The presence of sub- 
stances in the urine, which can only come from the intestines is, in 
most cases, a pathognomonic sign of grave and deep-seated altera- 
tions which no other symptom could have revealed. 

In cases in which a perforation has taken place between the 
bladder and rectum, it is often possible, by introducing a probe into 
the bladder and a finger into the intestine, to feel it; it may even 
happen that the opening of the communication is sufficiently large 
to admit the passage of the finger itself from the rectum into the 
bladder. 

A great many substances administered under the name of med- 
icines and introduced into the stomach, may be discovered in the 
urine. Chemists assert that they have found, in the urine, iodine, 
mercury, arsenic, iron, the acetate and tartrate of potash, the 
alkaline sulphates and carbonates, the nitrate of potash, the sul- 
phate of quinine, etc. 

The urine, left to itself, does not generally preserve that homo- 
geneousness which it has at the moment of excretion. Many of 
its elements become separated from its mass, and form pellicles, 
deposits and various suspensions. To thoroughly appreciate these 
various phenomena, it is necessary to place the urine in a trans- 
parent vessel at the very moment of excretion, and leave it, for five 
or six hours at least, in a state of repose. 

The pellicle, cream or crown (urince corona, cre?nor) is a sort of 
very thin membrane that forms upon the surface of the urine. 

The suspension which begins to appear in the urine some hours 
after excretion, is of two kinds; the first, called nebula (nubecula, 
nubes), is that which forms near the superior surface of the fluid; 
the second, which settles near the bottom, is called etiaiorema* 
We may also observe in some cases a mean suspension in the 
urine, midway between the surface and the bottom, which has re- 
ceived no particular designation. The urine presents these various 
suspensions in most acute diseases. According to some authors, the 
suspension is more or less removed from the bottom of the vessel, 
in proportion as the disease is nearer its termination or otherwise. 
This rule, however, has numerous exceptions. 

Deposits, also called sediment (sedimentum, hypostasis'), f are 
caused by the heaviest substances reuniting at the bottom of 
the vessel, and forming a stratum of greater or less thickness. 

* ^Evuii^nrjua, from uw>(>iu), 1 raise. 

t Yixooxaoig, from v/rooruio, I am under. 

19 



218 



SYMPTOMS. 



Sediment does not generally appear till towards the decline of acute 
diseases. It does not always form at this period, but it is rare to 
observe it at any other. Ancient writers laid much stress upon 
the importance of sediment as a diagnostic sign of intermittent 
fevers. They considered this phenomenon invariable in the third 
stage of the paroxysms. Sediment not only collects upon the 
bottom of the vessel that receives the urine, but forms often upon 
its lateral walls a thin stratum, sufficiently defined, however, to 
give the fluid a turbid appearance. Upon inclining the vessel, this 
disappears, and we then see on one side perfectly transparent urine 
underneath the deposit, and on the other, the deposit alone forming 
an opaque coat upon the walls of the vessel. The sediment is 
generally of a whitish or grayish color; as frequently, perhaps, in 
intermittent fevers {sedimentum lateritium), it is of a rosy color, 
or the color of brick dust. It is often brown or black in jaun- 
dice and some acute fatal diseases ; and in a few extremely rare 
cases, of a bluish color, owing either to the presence of a peculiar 
substance, called by M. Braconnot cyanourine, or to hydrocyanate 
of iron, according to the observations of M. M. Julia,* Battf and 
Mojon. J The sediment often has the appearance of dust, or of 
meal or bran coarsely ground ; this is the furfuraceous sediment, 
{sedimentum furfuraceum) •§>. At other times it is formed of a 
mucous matter either united into flocculi, or collected at the bottom 
of the vessel in an even and semi-transparent stratum. This is 
the mucous sediment. We designate by the epithet sandy or 
gravelly, the sediment that contains sand or gravel {sedimentum 
arenosum). Purulent sediment is that consisting of pus, etc. 
Deposits, nebulas, and pellicles that form in the urine have been 
examined by the microscope and subjected to chemical analysis. 
The nature of these various urinary products varies according as 
the urine itself is acid or alkaline. In acid urine, the nebulas and 
enaeoremata are formed by thin lamellae of epithelium, urates, 
uric acid and mucus. The yellow, reddish or red sediments are 
formed of uric acid or urate of ammonia, distinguishable from 
each other by their modes of crystallization which the micro- 
scope enables us to determine with precision. Alkaline urine, more 
or less discolored, is generally accompanied by a white or slightly 
yellow sediment disposed into regular crystals, or forming an 
amorphous and pulverulent mass : this sediment is generally com- 
posed of phosphate of lime and the ammoniaco-magnesian phos- 
phate, mingled often with pus adulterated by ammonia, which 
gives it a viscous or mucous appearance. We may also find in it 
sanguineous globules, spermatozoa, the coloring matters of the bile , 
and occasionally various salts of which lime forms the base, etc. 

* Journal de Chimie, vol. 1, p. 330. 

j- De Urind Sedimentum Ceruleum Demittente, 1809. 

j Journal de M'tdec, vol. 72, p. 174. 

§ Furfur, meal. 



SYMPTOMS. 219 



§ III. Excretions. 

Having examined in succession the principal morbid phenomena 
presented by the secretions, it remains to say a few words with 
regard to the derangements of the excretions, independently of 
those of the secretions. 

The excretions which are under the influence of the will, are 
those alone of sufficient importance to be discussed in this place. 
These excretions may become in disease more or less frequent than 
in health, and may be accompanied with considerable efforts or 
be effected too easily. They may be involuntary, as in many grave 
diseases, and on the other hand, the will may be unable to promote 
them, as in cases of retention of the urine and occlusion of the 
rectum by hardened faeces. Sometimes the desire of excretion is 
continual, painful and almost ineffectual, as in tenesmus of the 
rectum or bladder. We can here only refer to these symptoms, 
as they have been discussed elsewhere, but must confine ourselves 
to the consideration of the phenomena which have not yet been 
enumerated ; such are those which arise from the occlusion of the 
excretory canals, whether these canals are, or are not, provided 
with sphincters, and whether the excretions are involuntary or 
otherwise. 

The causes which produce occlusion of these canals are very 
various, but may be divided into three classes. The canal is 
sometimes choked by an obstacle contained in its cavity, a calcu- 
lus, for example : sometimes its cavity is obliterated by the thick- 
ening of its walls, and sometimes by an external compression, as 
of a neighboring tumor. This occlusion is followed by various 
results. 1. The excretions of the fluid is prevented. This sup- 
pression is often difficult to prove during life in cases in which the 
secretory organs being double, like those of the urine, the occlu- 
sion of one of the excretory canals does not entirely interrupt the 
excretion of the fluid ; and in those cases in which the functions 
of the secretory organs are of minor importance or merely auxil- 
iary. But whenever the viscus to which the obliterated canal 
belongs is single, and plays an important part in the economy, as 
the liver, for example, the occlusion of the canal is soon followed 
by remarkable phenomena, such as acute pains, a yellow color in 
the skin and urine, discoloration of the faecal matters and various 
derangements of the digestive functions. 2. Another consequence 
of occlusion is distension of the canal from its source to the obsta- 
cle, and after a certain time its contraction and, sometimes, entire 
obliteration from the obstacle to its point of termination. This 
distension is apparent in the duct of Steno, vasa deferentia and la- 
crymal sac, but entirely escapes our direct observation whenever 
the organ is deeply seated, as, for example, the liver, kidney and 
pancreas. 3. The progressive distension of the canals by the 
fluids which incessantly flow into them, represents a force which 
has a tendency to remove the obstacle which produces the occlu- 



220 SYMPTOMS. 

sion, to raise the tumor which presses upon the canal, to dilate its 
lateral walls, or to push before it the foreign body contained in it. 
In this last case, the distension of the canal, as far as the calculus, 
would seem to favor its progression ; for it is difficult to suppose 
that this distension being so considerable as far as the calculus, 
might not extend beyond it. And, on the other hand, the obstacle 
being situated at the point of junction of two portions of a canal, 
one of which is continually dilating while the other preserves its 
natural size, may frequently fall back into the dilated portion, and 
by its displacement suffer the collected fluid to escape through the 
opening, at least for a time. 4. Lastly, if the obstacle is neither 
pushed out nor displaced, death, sooner or later, may be the conse- 
quence, as in cases of retention of urine, intestinal matters and 
bile, sometimes by the rupture of the canal above the obstacle, and 
sometimes, by the retention in the economy of substances natural- 
ly excreted, the changes they undergo, the inflammation they pro- 
duce in the parts containing them, and. in some cases, the infection 
which follows their absorption into the circulatory current. 



SECTION SIXTH. 
Symptoms furnished by Absorption. 

Having examined the principal disorders of the secretions and 
excretions, it remains for us to speak of those presented by the 
different species of absorption. 

We may remark, in the first place, that in a great number of 
cases, derangements of absorption may be confounded with those 
of exhalation, since the same phenomenon, the accumulation of 
serum in the pleura or peritoneum, for example, may be equally 
the result of a diminished absorption or an increased exhalation. 

But there are other circumstances, under which it is impossible 
not to recognize the effect of absorption. The gradual or rapid 
disappearance of pus collected in a bubo, of blood extravasated 
under the skin in consequence of a contusion, of serum in the 
cellular tissue or in a serous membrane, are evidently phenomena 
which absorption alone can produce. Primary ulceration, when 
not arising from a loss of substance, or from the separation of an 
eschar, is regarded by most physicians as the result of a morbid 
absorption acting upon the solids themselves, and carrying away 
into the current of the circulation the elements of which they 
consist. 

It is generally believed that there is between the different absorp- 
tions an analogy similar to that existing between the different 
secretions. 

Thus, when absorption is very active in the digestive canal, 
after eating, for example, the exterior absorption, cutaneous and 
pulmonary, is probably diminished. It undoubtedly becomes more 
active in the morning before breakfast, since at this period of the 



SYMPTOMS. 221 

day the gravity of the body is increased, as was proved by the 
experiments of the celebrated Sanctorius, who, from the zeal and 
perseverance with which he devoted himself to these inquiries, 
deserves to have disciples and rivals. Many practitioners think, 
not without reason, that medicinal preparations left to the action 
of cutaneous absorption, mercurial ointment, for example, may be 
administered to greater advantage at this hour of the day. 

The absorption of the fat contained in the vesicles, in patients 
subjected to a severe course of diet, comes in aid of the opinion 
that when absorption is not sufficiently active in one part, it in- 
creases in another. The same may be said of the advantageous 
effects that sometimes follow a rigorous diet in the treatment of 
certain engorgements ; the absorption which, for want of sub- 
stance, is not effected in the digestive canal, acts with more energy 
in other parts, and may cause the progressive diminution of a 
hypertrophied viscus, as well as that of the whole body. Resolu- 
tion, which we shall consider in another place, appears to be noth- 
ing but a remedial absorption. 

Besides this kind of equilibrium, which we observe in disease 
between the secretions on the one hand and the absorptions on the 
other, there are also cases in which these two functions act in con- 
cert. In the course of an acute phlegmasia, pleurisy for example, 
so long as the disease is making progress, and a sero-purulent fluid 
is exhaled in the pleura, the skin is dry and the urine excreted in 
small quantities. But when the absorption begins to act upon the 
effused liquid, the skin often becomes moist and there is an abun- 
dant flow of urine ; analogous phenomena take place, and are more 
easily observed in the progressive diminution of anasarca and 
ascites. In these cases, exhalation carries away through the skin, 
kidneys, and mucous membrane of the digestive passages, a greater 
quantity of fluid, in proportion as absorption takes up the serum 
effused in the serous and cellular tissues. The considerable in- 
crease of certain secretions, the urine, for example, in diabetes, 
and abdominal serum in ascites, is necessarily connected with a 
similar increase of absorption, and especially the pulmonary or 
cutaneous absorption. The excretion of from twenty to forty 
pounds of urine daily, for many months together, in diabetes, and 
the daily increase of from ten to twelve pounds in the weight of 
the body in some cases of ascites, in which the amount of food 
taken is proportionally small, settle this question beyond a doubt. 
As a general rule, whenever absorption becomes very active in any 
tissues or organs, the exhalations and secretions become so in 
others, and vice versa. It is by the application of this law to the 
treatment of disease, that the physician endeavors to promote the 
absorption of fluid collected in the serous membranes by increas- 
ing the intestinal urinary or cutaneous secretions, and is sometimes 
enabled to diminish the urinary secretion in diabetes, by promot- 
ing profuse perspiration. 
19* 



222 SYMPTOMS. 

SECTION SEVENTH. 

Symptoms furnished by Nutrition. 

The derangements of nutrition in disease are almost infinite, 
but in most cases are not appreciable by the senses during life, and 
consequently do not belong to symptomatology. There are a few, 
however, properly within its domain, which we proceed to enu- 
merate. 

Nutrition may be increased, diminished or perverted. It can 
only be entirely lost in those parts already deprived of life. 

Increased activity of nutrition is indicated by the increased 
volume of all, or nearly all, the constituent parts of the body, but 
more particularly of the viscera contained in the chest and abdomen, 
of the muscles and of the adipose tissue. This may easily be con- 
founded with the obesity produced exclusively by an accumulation 
of fat in the cellular tissue. The latter phenomenon, though rare, 
may occur in disease (page 76), while a general increase of vol- 
ume of the muscles and viscera, is never a symptom. It is other- 
wise when this increase is partial : such is that of which the heart 
and liver are frequently the seat, and which we designate by the 
term hypertrophy, an affection rarely simple, and nearly always 
connected with some obscure modification in the texture of these 
organs, and particularly with some disturbance in their functions, 
more or less apparent. 

In nearly all diseases of any importance, nutrition becomes lan- 
guid. This is apparent from the emaciation that accompanies 
them. When this languid nutrition exists in but one part of the 
body, it gives rise to a partial emaciation or atrophy, a phenome- 
non particularly owing to the entire inaction of organs, or to a 
prolonged compression of them. It is also of frequent occurrence 
in the muscles of limbs under the influence of these two causes, 
and necropsies prove that the internal organs, as, for example, the 
lung in pleuritic effusion, may also become the seat of it under 
the influence of the latter cause. 

Atrophy of an organ may also follow a disorder affecting the 
circulation or innervation. This principle has been ingeniously 
and usefully applied to the treatment of certain diseases. Thus, 
Maunoir of Geneva, and Charles Bell, have produced the atrophy 
of a voluminous testicle, by a ligature round the spermatic artery ; 
and many other surgeons have arrested the progress, and brought 
about the decrease of considerable tumors in the face, by tying 
the common carotid artery on the corresponding side. The liga- 
ture or division of nerves often produces atrophy, also, in the 
muscles to which they are distributed. The suspension of nervous 
action appears, also, to have had the effect, in some cases, of ar- 
resting the development, and even causing the atrophy, of certain 
morbid tissues. Dr. Duparque * states that he saw an ulcerated 

* Maladies de V Uterus. 



SYMPTOMS. 223 

cancer of the breast diminish and disappear, in consequence of a 
paralysis affecting the side of the body corresponding to the dis- 
eased part. This fact, alone, perhaps, in the annals of science, 
requires confirmation. 

Emaciation should not be confounded with leanness. The lat- 
ter is that condition of the sound or diseased body in which there 
is a natural thinness of flesh ; while the former is that state in 
which there is a gradual wasting of the body. An emaciated per- 
son may still have embonpoint, and a person may be lean who is 
daily gaining flesh. We have spoken of this phenomenon in the 
article devoted to the exterior of the body (page 77), and do not 
propose to recur to it here. 

Nutrition is as often perverted as diminished. It is to this per- 
version that we may refer all the organic lesions which are not the 
result of an external cause : the production of cysts, vicious cur- 
vature of the bones, the various degenerations and the phlegmasia^ 
themselves, seem to be originally owing to a modification of nu- 
trition. 

Nutrition furnishes another class of phenomena which belong 
still more to symptomatology. We refer to the irregularities of 
growth in the growing period of life. The growth, which, in 
health, is effected in different individuals according to a variable 
progression, but always within certain limits, presents, in disease, 
many remarkable anomalies. We see children whose growth 
seems to be entirely suspended for one, and even for many years. 
This phenomenon is not uncommon in rachitis, of which it is 
sometimes the first symptom. We have seen at the Clinical 
School of the Hotel Dieu, a person fifteen years of age, affected 
with diabetes, whose growth had been suspended since he was 
twelve years of age, the period at which the diabetes had com- 
menced. We see a greater number of persons, whose length of 
body increases one, and sometimes several inches during the very 
limited course of an acute disease. These two opposite phenom- 
ena are equally of unfavorable augury, though the latter indicates 
immediate danger, while the former should lead us to fear that the 
development of the body is permanently arrested. 



ARTICLE THIRD. 

Symptoms furnished by the Generative. Functions. 

The symptoms of which we have hitherto spoken are, almost 
without exception, common to the two sexes, but those which it 
remains for us to enumerate are peculiar to the one or the other. 
Having already pointed out the principal changes that disease 
produces in the external organs of generation, in the section de- 
voted to the consideration of the exterior of body, we shall now 
merely say a few words upon the disorders of the functions de- 
signed for the reproduction of the species. We shall consider them 
successively in man and woman. 



224 SYMPTOMS. 

A. In man, the secretion of semen is seldom increased in disease. 
It may occur, however, in erotic melancholy, and is one of the 
principal symptoms of satyriasis The diminution, or almost en- 
tire suspension, of this secretion is, on the contrary, of frequent 
occurrence, as may be inferred from the constant flaccidity of the 
penis and the absence of erection, in the course of most diseases. 

The excretion of the semen is susceptible of different disorders. 
It is attended with pain in the phlegmasia? of the urethra. With 
some individuals it takes place when the penis is not in a state of 
erection, particularly during the efforts attending stools. In other 
cases, the emission is feeble, or interrupted by some obstacle (dis- 
permasia)* and the seminal fluid, instead of being excreted in jets, 
flows slowly through the orifice of the urethra. In some persons, 
emission takes place upon a simple touch, and before the introduc- 
tion of the penis into the vagina. Sometimes there is a deviation 
of the semen, which, after being forced into the canal of the ure- 
thra, flows back into the bladder whence it is excreted mingled with 
urine. This deviation is owing to the wrong direction of the 
ejaculatory ducts which open into the canal of the urethra, from 
before, backward, that is, contrary to the natural arrangement. 
It sometimes follows, also, stricture of the urethra. 

Impotency, or inability to effect the venereal act, may arise from 
a multitude of different causes, the consideration of which would 
be irrelevant in this connection. We will merely remark, after re- 
ferring to the influence of imagination upon this phenomenon, that 
sometimes the penis is not capable of erection, and sometimes 
emission does not take place, at least at the proper time. The loss 
of power of erection is, in a certain number of cases, the first, or 
one of the first symptoms of a disease of the nervous centres, and 
particularly the spinal marrow. 

We observe, in some cases of disease, frequent and even habit- 
ual erections, taking place independently of the natural causes 
that excite them. This phenomenon occurs, particularly, in cases 
of vesical calculi, and in certain chronic eruptions of the skin. 
The application of a blister will produce it in some persons. 

B. In woman, the functions of reproduction present a greater 
number of symptoms. The menses, the lochia, and the secretion 
of milk deserve particular attention. 

In some young females the catamenia do not appear at the 
usual age. This delay may be owing to the general state of the 
constitution, or be connected with the condition of the uterus or its 
appendages. In most cases, however, it is referable to disease in 
a remote organ, and particularly the lungs. 

The menstrual flux is sometimes increased in disease. This in- 
crease, when very considerable, constitutes menorrhagia, and may 
take place at the usual menstrual periods, or in their intervals. 
When the blood escapes in clots, it is always important to examine 

* Jvg, with difficulty ; ojitQua, semen. 



SYMPTOMS. 225 

it with care, in order to ascertain whether it contains a fetus or its 
membranes, particularly when the flow of blood is accompanied with 
expulsory pains analogous to those of parturition. Metrorrhagia 
is often symptomatic of abortion either in progress or already effect- 
ed, and is sometimes connected with disease of the uterus, such as 
polypus, fibrous tumor, cancers, granulated metritis, etc. Metror- 
rhagias, or morbid haemorrhages of the uterus, sometimes occur 
spontaneously in the course of acute diseases, particularly dur- 
ing eruptive fevers and variola, and give a graver character to 
prognosis. In all these cases an examination of the uterus by the 
touch is indispensable. The diminution of the periodical flux is 
much more frequent, occurring in most chronic affections. In 
their last stage it is almost always suspended. Deviations of the 
menstrual flux have also been very frequently observed, and may 
take place through a great number of different passages, but par- 
ticularly through one of the mucous membranes or the skin. 

The flow of lochia after parturition, may be unusually great; 
more frequently, however, if any disease exist at this period, this 
discharge is much diminished in quantity, and sometimes even 
entirely suppressed, as in puerperal peritonitis. 

The volume of the mammas is increased during pregnancy. 
This phenomenon occurs, also, but rarely, in certain affections of 
the uterus. There are a great number of females whose menstrual 
periods are preceded and accompanied by a perceptible tumefac- 
tion of the mammas, while at the same time they become the seat 
of a sensibility more or less acute. It is particularly, however, a 
few days after parturition that the mammas present a great in- 
crease of volume, at the time that the secretion of milk is effected. 
The absence of tumefaction of the mammas or their sudden falling 
away, under such circumstances, is always a suspicious phenome- 
non. The mammas dimmish in volume, and sometimes become 
actually atrophied, in women advanced in years. 

The secretion of the milk never increases during the progress of 
disease, but nearly always diminishes, and is sometimes suppress- 
ed. This suppression is generally accompanied by shrinking of 
the mammas, and sometimes by their induration, a phenomenon 
attributed by some authors to the coagulation of the milk in the 
mammary gland. — The microscopic examination of the milk is not 
without interest in a pathological point of view. By means of this 
examination, the milk has sometimes been found to be mingled 
with small quantities of pus. — With regard to deviations of the 
milk, of which so much has been said, and which was once thought 
to have been proved by the milky appearance of pus in abscesses, 
of leucorrhasal mucus, or of the fluid furnished by the inflamed 
pleura or peritoneum, they are no longer believed to take place, 
and consequently need not here be discussed. The facts, that we 
find this lactiform matter in men as well as women, and that if it 
present the color of milk, it has none of its properties, are sufficient 
to overthrow the hypothesis if it still has any advocates. Women 
are also accustomed to attribute the fixed or undefined pains, and 



226 SYMPTOMS. 

the cutaneous eruptions that follow delivery, to the presence of 
milk in the economy. They designate these symptoms, whatever 
they may be, by the term diffused milk. This second species of 
deviation is a mere unfounded hypothesis. 

Barrenness may follow more various causes than those that give 
rise to impotency in man. The most common, are vicious confor- 
mation or position of the os uteri, the obliteration of the fallopian 
tubes, the various lesions of the ovaries, and the presence of polypi 
in the neck of the uterus. 

We may also refer to this head of disorders furnished by the 
generative functions of women, the facility with which abortion is 
effected in some, and the inability of others to carry the product of 
conception during the natural period of pregnancy. 

In both sexes the venereal desire {appetilus venerens) may be 
increased, diminished or perverted. It is increased in satyriasis 
and nymphomania, and in some cases of erotic melancholy. It is 
diminished in most diseases, and particularly in leucorrhea in 
women, and in both sexes in persons addicted to masturbation. 
Its entire loss is designated by the term anaphrodisia (anaphrodi- 
sia.*) It is perverted in certain cases of mania, and some other 
neuroses, in which the patient is incessantly addicted to masturba- 
tion, or is led to the commission of unnatural acts. 

Such are the principal symptoms furnished by the generative 
functions. To these we may add those that are discovered by 
touch and the speculum uteri, of which we shall give a summary 
in the chapter on diagnosis. 



ARTICLE FOURTH. 

Symptoms considered in Disease. 

Having thus far treated of symptoms in the abstract, we shall 
now proceed to consider them in connection with disease, of which 
they constitute the elements. 

Sometimes but one symptom makes its appearance ; as in cases 
of vomiting, deafness or epistaxis ; but generally many occur 
simultaneously. These symptoms are grouped in a thousand 
ways, and by their various combinations, constitute the phenome- 
nal part, or the apparent features of a disease : they lead to the 
knowledge of internal lesions when these exist, and are of the 
highest importance, in all cases, in enabling us to decide upon the 
nature of the disease with which the patient is affected. The 
symptoms which appear simultaneously in the same patient, are 
often in intimate connection with each other ; they are not all of 
equal importance, either in relation to the diagnosis of the disease 
or the influence they may exert upon its progress ; lastly, they do 

* A privative, acpQoSloia, pleasure. 



SYMPTOMS. 227 

not all appear at the same time. We shall now briefly consider 
them in these different points of view. 

$ I. It is highly important in the appreciation of symptoms, to 
be able in a case of general functional disorder, to distinguish 
which function was primarily affected, and not to confound symp- 
toms which may be called primary, or local, with their accompany- 
ing secondary, or general, phenomena. In pleurisy, for example, 
there may be observed simultaneously, redness of the face, pain 
in the chest, feebleness or disorder of the intellectual functions, 
thirst, interrupted voice, cough, dyspnoea, frequency of the pulse, 
increased heat, high colored urine, and many other symptoms 
which may accompany the disease during the whole, or a part, of 
its duration. The importance of isolating the primary, from the 
secondary, phenomena, is here evident. The first, are pain in the 
side, dyspnoea, and cough, to which may be added the difficulty 
of speech ; the second, are the color of the face, headache, frequency 
of the pulse, heat, disordered secretions, &c. The sensible changes 
presented by the inflamed pleura explain all the primary phenom- 
ena, as the pain, dyspnoea and cough. The connection between 
the symptoms and this disease may be also easily explained. The 
pleuritic pain, and probably also the inflamed state of the pleura, 
oblige the patient to take short and frequent inspirations ; respira- 
tion is so intimately connected with the circulation, that when one 
is accelerated the other necessarily becomes so. The frequency 
of these two functions causes elevation of heat, in the production 
of which both appear to concur ; the increased heat augments the 
thirst, and renders the urine more highly charged. 

But it is impossible, in most cases, to discover the connection 
between the various symptoms, and we are compelled to attribute 
them to the invisible bond of sympathy. The relations between 
all parts of the body in health as well as disease are so intimate, 
that no one can become gravely affected in its structure or func- 
tions, without all the others, or at least many of them, participa- 
ting in some degree. Sympathetic phenomena, are those which 
arise from this connection alone between the different organs, un- 
accompanied by any primary lesion of the part which is their 
seat, and sympathy * is the term applied to the organic condition 
which presides over the production of these phenomena. This 
produces, in disease, effects more various and extraordinary than 
in health. Without here speaking of that universal or general 
sympathy, by virtue of which the whole economy participates in 
the disorder of some organ or function, as is observed in the in- 
flammation of a viscus or any other internal disease, let us con- 
sider for a moment the phenomena which depend upon special or 
particular sympathy, or that which exclusively exists between 
certain organs. 

Hunter divided these numerous and various phenomena into 

* 2w t with, at the same time; naQog, affection. 



228 SYMPTOMS. 

three series, according to their appearance in organs which are 
continuous, contiguous or remote ; this division is more simple and 
natural than those since established. To the sympathy of con- 
tinuity, may be referred the pain felt in the whole track of a nerve 
when any part of it is irritated or contused ; the general convul- 
sions and tetanus following laceration of a nervous filament ; the 
itching of the nasal fossae in persons affected with intestinal worms, 
and pain in the glans penis in those affected with calculus in the 
bladder. The sympathy of contiguity produces vomiting in perito- 
nitis, dysuria in hemorrhoidal swelling, dysentery, &c. Remote 
sympathy sometimes affects similar organs, or those associated in 
the performance of the same function, and, sometimes, parts be- 
tween which no relation exists. In complete amaurosis of one 
side, the oscillations of the iris are sometimes observed to be trans- 
mitted from the sound eye to that which is incapable of distinguish- 
ing the light, and, when one of these organs is inflamed, the other 
cannot endure the light. These various phenomena are attributa- 
ble to the similarity in the structure and functions of the affected 
organs. The relation existing between the mammae and uterus, 
and between the expiratory muscles and lungs, seem to account, 
to a certain extent, for the shrinking or swelling of the mammae in 
certain affections of the uterus, and the involuntary cough excited 
by the accumulation of mucus in the trachea. The examples of 
remote sympathy between two organs which do not concur to the 
performance of the same functions, are very numerous, and can- 
not be explained by nervous anastomoses, although many physi- 
cians have thus endeavored to account for it in some sympathetic 
phenomena of this kind, and particularly in the pain of the right 
shoulder, sometimes accompanying inflammation of the liver. 
The cough sometimes observed in certain affections of the stom- 
ach, liver and uterus ; the vomiting which occurs in diseases of 
the brain, lungs, kidneys and uterus ; the trembling of the lower 
lip and ptyalism which often precede vomiting, dilatation of the 
pupils in verminous affections, and pain in the knee in hip disease, 
are all sympathetic phenomena, most of which have been noticed, 
but which are entirely inexplicable. 

Such are the principal effects of morbid sympathy, which, as 
has been said, transmits throughout the economy the irradiations 
of the affected organ. 

$ II. The symptoms which appear simultaneously in the course 
of any disease, are not all of equal importance. There are those 
which are principal or characteristic, and others, that are called 
accessory. 

When all the functions of the economy are simultaneously de- 
ranged, many of them severely, no organ being more particularly 
affected than the others, the most apparent phenomena become the 
principal symptoms, the others being only accessory : this is par- 
ticularly observed in malignant intermittent fevers. In those 
diseases, on the contrary, in which a single organ is the seat of the 



SYMPTOMS. 229 

affection, the importance of the symptoms is not determined by 
their intensity, but by their seat and the function which is de- 
ranged. Thus in peripneumony, a slight pain in one side and a 
few rusty colored sputa are the principal symptoms ; while the 
violent headache, high colored urine, and high fever, are but ac- 
cessory phenomena. 

§ III. Symptoms have been also divided into active and passive. 

In defining disease to be a struggle of nature, in which she is 
endeavoring to repel or destroy the morbid cause, it seems to be 
forgotten that, in some affections, no sign of salutary reaction can 
be perceived, and that most of the symptoms tend, on the con- 
trary, to hasten the fatal result. Thus in pulmonary phthisis, the 
night sweats, diarrhcea, cough and haemoptysis, daily aggravate 
the condition of the patient. But there are, also, other affections 
in which no favorable reaction can be discovered. The peculiar 
phenomena developed around a thorn imbedded in the skin, the 
fever which accompanies the inflammation of this membrane and 
the subjacent parts, the suppuration which occurs around the for- 
eign body, and causes its expulsion after having produced absorp- 
tion of the integuments in the part corresponding to the abscess, 
or destroyed the edges of the opening which gave exit to the 
material agent of the disease, are symptoms which we may, with 
some modern authors, term active. 

In many acute diseases, most of the symptoms seem also to 
indicate, if not a concurrence of all the forces of the economy 
against the morbific cause, at least an evident struggle between 
them. But it must be admitted that, in most cases, the distinction 
into active and passive symptoms is utterly impossible. 

§ IV. All the symptoms do not make their appearance at the 
commencement of diseases. In those whose course is rapid, 
the principal and characteristic symptoms are generally developed 
about the second or third day; in those which progress slowly, 
they may not appear for several months, and sometimes many 
years. In both cases, various accidental symptoms, called epi- 
phenomena, * occur in the course of the affection, which differ 
from symptoms, properly so called, in not being as intimately con- 
nected with the existence of the disease. To the epiphenomena, 
or accidents, may be referred the supervenientia, the epigenemata, 
and, what have been styled in the schools, the symptoms of the 
cause, and the symptoms of the symptom. The supervenientia 
are phenomena foreign to the disease, but developed by it ; as the 
appearance of the menstrual flux before the ordinary period ; the 
pains of dentition occurring in children, but which were not ex- 
perienced previous to the existing disease ; and finally, the prodi- 
gious multitude of parasitic animals, worms, and particularly lice, 
observed in some patients. The epigenomata are accidents mani- 

*"E/ti, upon; (paivoiiai, I appear. 

20 



230 PROGRESS OF DISEASES. 

fested during the disease, but which depend upon some external 
cause, as the negligence of the assistants, or imprudence of the pa- 
tients themselves. The symptoms of the cause are accidental phe- 
nomena which seem to depend, not upon the disease, which does not 
ordinarily produce them, but upon the determining cause of the 
disease itself; as in the case of haemoptysis occurring in the course 
of an inflammatory fever. As this symptom does not ordinarily 
accompany this disease, it has been considered rather the result of 
the phlethora which produces the fever, than of the fever itself. 
Finally, should this haemorrhage become sufficient to cause fainting, 
the latter would be considered, in the language of the schools, the 
symptom of a symptom. These distinctions have been justly 
abandoned, and their distinctive appellations have become to us 
almost unintelligible. The various accidents which may be added 
to the symptoms of disease may, withoutin convenience, be classed 
under the head of epiphenomena. 

Such are the principal points of view in which symptoms may 
be considered. In the chapter on diagnosis, we shall consider 
their semeiological value. — O. 



CHAPTER VIII. 



PROGRESS OR COURSE OF DISEASES. 



The progress of diseases (morborum decnrsi/s) may be defined 
to be the mode of production and succession of the material lesions 
and symptoms which characterize them. 

The alterations occurring in the texture of organs during disease, 
elude, in many cases, our means of observation. There is, how- 
ever, *a considerable number of diseases in which we can, to a 
certain extent, trace the internal modifications and most apparent 
functional derangements. Without mentioning, in this place, those 
diseases whose seat is the cutaneous surface, or those occupying 
the orifices of the mucous membranes, or parts so near to these 
orifices, that the eye can observe and follow through their various 
phases, the changes which occur in their material disposition ; 
there are certain other affections, as pleurisy, pneumonia and 
scirrhus of the stomach, in which, by the aid of all our explorative 
means, we are able to recognise the commencement, progress and 
diminution of a pleuritic effusion, the progressive conversion of 
pulmonary engorgement into hepatization, the extension of the 
disease from the point primarily affected, to other portions of the 
same organ, and the gradual increase of a tumor developed in the 
greater curvature of the stomach. But it should be recollected 
that material organic lesions are in most cases appreciable only 
after death ; and in many instances, it is almost wholly by the 



PROGRESS OF DISEASES. 231 

alterations which supervene in the symptoms, that the physician 
can trace and study the progress of diseases, in which are com- 
prehended their type, their form, either acute or chronic, the dis- 
tinction of their periods, and the examination of the numerous 
circumstances which influence them. 

§ I. The type {typus) is the order in which the symptoms 
become aggravated or reproduced. 

It is continued (T. continuus) when the symptoms persist unin- 
terruptedly from the commencement to the termination of the 
disease ; periodical or intermittent ( T. periodicus, intermittens), 
when they appear and disappear at intervals. 

A. A disease of continued type is sometimes equally intense 
throughout its course : it is then called continent {morbus conti- 
nens) ; such is, in certain cases, the ephemeral inflammatory fever, 
exhibiting, during its short continuance, variations so slight as not 
to deserve notice ; no acute disease would be continent, if this 
term be employed in a strict sense. The continued diseases 
are not usually of uniform intensity; they have exacerbations 
alternating with the decrease of the symptoms or remission. The 
exacerbation, paroxysm or access, consists in a more or less marked 
increase of one, many, or all of the symptoms belonging to the 
disease ; the remission, in the opposite change. 

There are certain continued affections, whose symptoms, instead 
of presenting these opposite alternations, increase regularly in in- 
tensity from the attack to the termination ; there are others, on the 
contrary, which exhibit their greatest intensity at their commence- 
ment, and become gradually less serious. The fever which pre- 
cedes the appearance of the catamenia, often exhibits an increasing 
intensity ; the contrary has been observed in regard to ephemeral 
fever. 

B. Periodical or intermittent diseases assume very various 
forms, either in regard to the actual paroxysms* (accessus), (such 
is the name given to the reappearance of the symptoms) or to the 
interval between them. Certain paroxysms present, in the midst 
of variable symptoms, a chill, succeeded by heat and perspiration; 
others, which are also called attacks, do not exhibit these phenom- 
ena. The first are peculiar to intermittent fever ; the latter are 
common to all other periodical diseases, such as epilepsy, hysteria 
and many nervous affections. The interval between the febrile 
paroxysms is called apyrexiaf or intermission (apyrexia, inter- 
missio); the intermediate periods of the attacks have received no 
particular appellation. 

The intermittent or periodical type may present itself under" 
various forms : the principal are the quotidian (quotidia?ius), ter- 

* flaQoivtiftbg, ofy'f, acute ; naglx, beyond, 
t A privative, yv()i$b$, fever. 



232 PROGRESS OF DISEASES. 

tian {tertianus), and quartan {quartanus"). In the first, the par- 
oxysms occur every day, and resemble each other in duration, 
violence and principal symptoms ; in the second, the paroxysms 
occur every second day ; in the quartan type, every third day. 
A type presenting recurrences every fifth, and one every sixth 
day, have been admitted ; but they have been very rarely ob- 
served, and many practitioners have thought that the reappear- 
ance of certain fevers with these unusual types should be consid- 
ered accidental. The existence of monthly or annual intermittent 
fever is not now admitted. When an intermittent disease reap- 
pears at irregular intervals, it is erratic or atypic {morbus erra- 
ticus). 

The quotidian, tertian, and quartan types present numerous 
varieties : 1. In the double quotidian {quotidianus duplex), two 
paroxysms occur every day. 2. In the double tertian (tertianus 
duplex), there is a paroxysm every day, those of alternate days 
corresponding ; the third resembling the first, the fourth the second. 
3. In the duplicated tertian {tertianus duplicatus), there are two par- 
oxysms on the same day and one day of apyrexia. 4. If the type 
be triple tertian {tertianus triplex), there are two paroxysms on 
the first and on the third day, and one only on the second and 
fourth ; these paroxysms correspond every second day. 5. The 
double quartan type {quartanus duplex) has one paroxysm on two 
successive days ; the paroxysm of the fourth day is similar to that 
of the first, that of the fifth to that of the second, the apyrexia of 
the sixth day corresponds to that of the third. 6. In the duplicated 
quartan {quartanus duplicatus), there are two paroxysms on the 
same day, occurring every third day. 7. In the triple quartan 
{quartanus triplex), there is a paroxysm each day, as in the quo- 
tidian and double tertian ; but in the triple quartan, the paroxysms 
correspond as to the hour, duration and severity, on each third 
day ; the first three differ from each other, the fourth resembles 
the first, the fifth the second, the sixth the third; in the double 
tertian type, the paroxysm is different every other day, and corres- 
ponds every second day ; in the quotidian there is constant simi- 
larity of access. Of all these varieties of intermittent types, the 
double tertian is the only one frequently met with : all the others 
may be considered exceptional. 

C. Diseases, and fevers in particular, occasionally run an inter- 
mediate course between the continued and intermittent types; this 
is called the remittent type {remittens). Like the intermittent, it 
presents paroxysms of rigor, heat and sweating ; and like the con- 
tinued type, certain symptoms which persist uninterruptedly 
throughout the disease. Such is the exact definition given by 
Pinel of the term remittent ; for, before his time, physicians con- 
founded under this title, continued fever with exacerbations and 
remittent fevers properly so called. 

The cause of the periodicity of diseases is one of the most ob- 
scure points in general pathology. We consider it quite natural 



PROGRESS OF DISEASES. 233 

that phlogosis, degeneration, or any other organic alteration, should 
produce phenomena which continue without interruption, as does 
their determining cause. But it is quite otherwise with diseases 
which disappear and return at intervals, particularly if their re- 
turn be regular. If we suppose the existence of a material lesion, 
how does it happen that its action is only transient ? If functional 
derangement, unaccompanied by organic lesion, be assumed, we 
admit an effect without a cause. Many physicians have endeav- 
ored to explain a phenomenon whose conception even, presents 
such difficulty. The majority have concluded that the productive 
cause of the intermittent or periodical type ought to cease, at any 
rate, partially, by the very effect of the paroxysm ; but that this 
cause, engendered within, or introduced into the system, confined 
to one point or disseminated through the whole body, was after- 
ward reproduced with more or less promptitude, so as to excite a 
fresh paroxysm. The cause has, by some, been attributed to cer- 
tain fluids of the economy, as the mucus, the bile or the blood ; 
by others, to the nervous system ; by others still, to fermentation 
or remarkable disturbance, or to obstruction of the circulation in 
any part of the body, the vena porta, for instance ; by another 
class, it has been assigned to the sensitive principle; and lastly, 
some ascribe it to irritation or intermittent phlegmasia. 

These and all other explanations are pure hypotheses, unsup- 
ported by sound reasons, and the majority of which are in opposition 
to facts. The periodicity of diseases is well known, but inexplica- 
ble. We recognise it, moreover, in a multitude of phenomena both 
out of the system and within it, and in no way can it be explained. 
The ebb and flow of the sea, the sleep of vegetables and animals, 
the regularity of the menstrual and hsemorrhoidal discharges, are 
each phenomena whose periodicity is as difficult of explanation as 
that of diseases. This, then, should rather be attributed to the 
weakness of human understanding than to the imperfection of the 
science. 

$ II. Diseases have been divided by authors into acute and 
chronic, chiefly from their duration. We think, however, that 
there is a certain number which are acute in their course, although 
by their duration they belong to the chronic diseases ; as also there 
are others, chronic in their course, but acute in duration. A dis- 
ease is acute in its progress when the development, succession, and 
intensity of its characteristic symptoms announce an affection 
necessarily of short duration ; on the contrary, when the symptoms 
appear, increase and succeed one another slowly, its course is 
essentially chronic. A typhoid fever which passes the fortieth and 
even the sixtieth day, is still an acute disease; a tubercular affec- 
tion is a chronic disease, although it prove fatal in a shorter time. 

§ III. All authors have divided disease into a certain number of 
periods ; * this is the name applied to each of its successive phases. 

* IlfQlofios, circuit; otfoj, path ; ntql, around. 

20* 



234 PROGRESS OF DISEASES. 

The number of periods in disease has not been determined ; the 
majority of authors recognise four or five ; others have enumerated 
even eight in certain affections. With M. L. Beauvais, we shall 
admit three only, each distinguished by an important and last- 
ing condition, as the increase, persistence and diminution of the 
symptoms, and we shall name them, according to universal usage, 
period of increase or progress, static, and declining periods. The 
invasion of the disease, being only its commencement, should not 
be considered as a period ; if it be, the moment of its cessation 
should be made one also. 

A. The first period, that of increase, progress (incrementum), 
extends from the invasion to the highest degree of intensity mani- 
fested by the symptoms. 

The invasion or first appearance (invasio, initium rnorbi), is the 
moment at which the disease commences. It is never, or very 
rarely, appreciable in chronic affections, and generally is recognised 
with certainty in acute diseases alone; and even in them, is fre- 
quently so indistinct that it is difficult, or even impossible, to sepa- 
rate it from the time immediately preceding or following. This is 
the case whenever the intensity of the precursory phenomena in- 
creases gradually, so as to lead the system by degrees from a state 
of health to disease ; or when an affection becomes manifest under 
certain natural conditions which have materially modified the 
functions, as for example, after parturition. Sometimes, it is true, 
rigor, syncope or some other remarkable phenomenon supervenes 
at such a time, which may be considered indicative of commencing 
disease ; but uncertainty often exists. 

The invasion of acute diseases, and especially those of a grave 
nature, is usually announced by a chill, of variable duration and 
severity; this is succeeded by heat, and alternates with it lor an in- 
definite period manifesting itself at one time suddenly, in persons 
previously healthy, at another, after several days of indisposition ; 
in most cases the patient is obliged to take his bed. 

Invasion is accompanied by certain other phenomena ; such are, 
a remarkable alteration of the countenance, tremor, convulsions, 
syncope, fixed pain in a particular organ, delirium, retching, vo- 
miting, dyspnoea, accelerated pulse, haemorrhage, etc. 

The invasion of most diseases may happen at any hour of day 
or night ; there are some which commence more particularly at 
certain hours. For example, paroxysms of asthma occur most 
frequently in the night ; those of intermittent fever, of the quoti- 
dian type, in the morning ; those of the tertian type, towards 
noon ; of the quartan, in the latter part of the day ; of symptom- 
atic intermittent fever, in the evening. This fact explains the ob- 
servation of many physicians, that intermittent fevers, whose 
paroxysms recur constantly at evening, usually resist the curative 
action of quinine; this remedy not acting in full force, except in 
cases of essential intermittents. 

The phenomena which announce the invasion of a disease are 



PROGRESS OF DISEASES. 235 

occasionally characteristic of it ; they then persist through its sub- 
sequent stages; but, most frequently, they cease from the first day, 
(as the chill which is common to all the acute affections,) and are 
replaced by others. 

The first period assumes various forms in different diseases. In 
those of an acute nature, the functional disturbance becomes daily 
more marked during the period of increase; the color of the skin 
is more decided ; the sensations and intellectual functions are 
sometimes deranged, the thirst is increased, digestion becomes 
completely depraved, the tongue is more or less coated, the pulse 
more frequent, the heat of the body more elevated and nearly all 
the evacuations are diminished or suspended. In chronic diseases, 
this period is distinguished by the gradual development of the 
principal symptoms. Its duration may be very short in some 
acute diseases ; it is usually of some months' continuance in chronic 
affections. 

B. The second or static period (violence, status, &*/"/), is distin- 
guished by the permanent intensity of the symptoms, and, occa- 
sionally, by the appearance of new phenomena of greater or less 
gravity. It commences when the aggravation of the symptoms 
ceases, and terminates when their intensity diminishes, or when 
the disease approaches a fatal termination. Its duration in acute 
affections is usually shorter than that of the first period, in certain 
cases, however, it is longer. 

C. The third period, that of decline (decrementum), or termina- 
tion, we now merely mention, intending to devote an entire chapter 
to its consideration. 

These three periods do not exist in every acute or chronic dis- 
ease ; in certain fevers, the symptoms present, from the commence- 
ment, their highest degree of intensity ; the period of increase is 
not observed. In apoplexia fulminans there is but one period; in- 
deed, it is often instantaneous. The same is true of some chronic 
affections ; paralysis of any sense, deafness or amaurosis, for 
instance, is sometimes, from the moment of its occurrence, as com- 
plete as it will ever be in the lifetime of the patient ; neither 
increase nor decline is observed. In some inevitably fatal chronic 
diseases, the symptoms gradually increase in severity from the 
commencement to the termination ; there is, as it were, continual 
aggravation : the division into periods is not applicable to these 
cases ; in cancer of the stomach, for example, there are many de- 
grees, but properly speaking, no periods. 

There are some affections, on the contrary, in which the three 
periods are very manifest ; typhoid fever is an example, the exter- 
nal appearance being usually sufficient for the diagnosis of the 
disease and the appreciation of its period. 

In diseases whose course is intermittent, each access presents a 
succession of phenomena, somewhat analogous to the three periods 
of an acute affection. Each of the component parts of the access, 



236 PROGRESS OF DISEASES. 

viz., the chill, the flush and the sweating, is known by the name 
stage (stadium). The chill has been considered as the period of 
increase, the hot stage has been compared to the static period, and 
the sweating stage to the termination. Independently of the three 
stages presented by each paroxysm, the three periods of continued 
disease may occasionally be distinguished in the aggregate of the 
paroxysms. Thus, in the first week, the paroxysms progressively 
acquire a higher degree of intensity ; then, for about the same 
space of time, they maintain a uniform intensity ; a regular dimi- 
nution, and finally, a spontaneous termination ensue. But in most 
cases, after a few recurrences of the paroxysm, we arrest the pro- 
gress of the disease, and consequently, can no longer observe these 
modifications. 

These periods are not observed exclusively in affections pro- 
duced by internal causes, they are also evident in those resulting 
from external causes. In superficial wounds we first observe the 
divided parts becoming red, gradually swelling more and more, 
and discharging a sero-sanguinolent fluid : when the inflammation 
has become more intense, suppuration is established, and after some 
days the phlogosis diminishes, while at the same time the edges of 
the wound adhere, and the cicatrix is formed. In this series of 
phenomena we clearly distinguish an incremental, a static, and a 
declining, period ; something analogous takes place in fracture, 
except that no purulent discharge exists, and that phosphate of 
lime is deposited in the tissue, originally cellular, afterwards car- 
tilaginous, which unites the fragments. 

In terminating this paragraph, it should be remarked, that, 
however distinct the periods may be, the transition from one to the 
other is almost always gradual and imperceptible, and that it is 
impossible to distinguish between the termination of one and the 
commencement of another. 

§ IV. The circumstances capable of modifying the progress of 
diseases are very numerous. Youth and adult age, sanguineous 
or bilious temperament, and a strong constitution, hasten that pro- 
gress and awaken a more lively reaction. The diurnal revolutions 
seem likewise to exert a very decided influence upon the course of 
diseases. Some of the ancient physicians thought that the four 
parts of the day might be compared to the four seasons of the year, 
viz : the morning to spring, mid-day to summer, the evening to 
autumn, the night to winter, and that each had an influence upon 
the exercise of the functions in health and disease, analogous to 
that of the seasons. Testa, who published a valuable work on 
the periods, inclined to this opinion, which should be admitted 
only with certain restrictions. Before sunrise, sweating is fre- 
quently observed, in both acute and chronic affections ; at this pe- 
riod, absorption appears to be somewhat increased ; oedema, when 
inconsiderable, disappears, and diminishes when excessive. It is 
at this time, as we have previously said, that we should employ 
absorbent remedies. Cruickshank assures us that venereal affec- 



PROGRESS OF DISEASES. 237 

tions which resisted frictions employed in the evening or night, 
were cured by them when made in the morning. At sunrise, the 
signs of plethora are more decided than at any other time ; the 
body is then more unwieldy and the head heavier : in some 
persons the fingers are so swollen that they can with difficulty be 
flexed ; the degree of heat is often uncomfortable ; at this time, 
also, the symptoms of cutaneous inflammation are usually more 
intense. The middle of the day induces a slight paroxysm in cer- 
tain chronic affections, particularly in pulmonary phthisis, and 
some periodical pains return constantly at this hour. The evening 
is the most common season for exacerbations or paroxysms in most 
acute or chronic diseases ; they persist and increase in intensity 
during the night, which usually has an unfavorable influence 
upon affections of a grave nature. Patients at this period, being 
fatigued by the impressions received during the day, experience 
more uneasiness; their pains, if any exist, become more severe; 
their attention is not easily arrested, and their memory is less sure 
than in the morning. It is almost always during the night that 
disorder of the intellectual functions begins to manifest itself; in 
some patients it reappears every evening, and ceases wholly during 
the day; in others, delirium, which is calm through the day, be- 
comes furious in the night. During the night the countenance is 
usually more animated, the thirst increased, the tongue less moist 
or more parched, the respiration more accelerated, the pulse more 
frequent, the heat of the skin more elevated, and the urine of a 
deeper color. 

Although the night may have an unfavorable influence upon the 
majority of diseases, there are many in which this is far more de- 
cided than in others ; among these are affections of the heart and 
lungs (particularly emphysema, and pulmonary tubercle), rheu- 
matic pains, etc. There are, indeed, certain affections, whose 
symptoms wholly disappear during the day, and manifest them- 
selves only in the night ; such are certain syphilitic pains and 
many eruptive diseases, as epinyctis. We have also seen a mor- 
billiform eruption reappear every night for nearly a month, in an 
individual who retained no trace of it by day. 

Some physicians have endeavored to discover the causes produc- 
tive of these regular variations in the progress of diseases, which 
correspond to the diurnal revolutions. M. Bally* asserts that 
light, or its absence, different degrees of temperature, and the 
unequal quantity of moisture diffused in the atmosphere, are the 
principal circumstances which determine the changes observed by 
day or night in the course of diseases. "Those manifesting 
themselves by exaltation of the vital forces, become aggravated in 
the daytime, those announced by prostration of the same forces, in 
the evening and night." This writer adds, in support of his opin- 
ion, that of eight cases of adynamic fever, seven terminated fatally 
between sunset and sunrise. If his opinion be correct as regards 

* De VInfluence de la Nuit, etc. Theses, 1807, No. 6. 



238 PROGRESS OF DISEASES. 

affections of an adynamic type, it is far from being true in those of 
an opposite nature ; daily experience will not allow us to admit 
that the paroxysms of inflammatory fevers, and of the phlegma- 
siae, take place in the daytime ; they are almost without excep- 
tion observed in the night. Before concluding our remarks, in 
regard to the influence of the latter period upon the progress of 
diseases, we should draw attention to the fact that it is not always 
injurious, and that frequently during its course, the gentle and 
general sweats commence which announce the arrest {detente) of 
the disease, according to the common expression, and lead us to 
hope that a favorable termination is at hand. 

The transient variations which occur in the temperature and 
moisture of the atmosphere, and in the direction of the winds, have 
but an uncertain influence upon the progress of chronic diseases, 
and seem to exert none whatever upon that of acute affections. 
A rapid change of temperature, however, especially sudden and 
severe cold, hastens the termination of chronic diseases which have 
attained their last stage. This is often observed in hospitals : 
when the temperature from having been for a long time mild, sud- 
denly becomes very cold, the greater number of patients who, for 
many days, have been struggling with death, will succumb in from 
twenty-four to thirty hours. In hospitals allotted to old men, the 
disastrous effect of cold upon the moribund is still more evident ; 
but the time of the falling leaf, so dreaded by the lower classes, is 
not generally more fatal to phthisical patients than the other 
seasons of the year, when sudden changes of temperature occur. 

Many patients, more particularly those laboring under rheumatic 
and nervous affections, are persuaded that the intensity of their 
pains augments or diminishes under the influence of certain atmos- 
pheric conditions : many such persons believe they can accurately 
foretell the changes about to take place in the atmosphere, by the 
degree of severity of their pains ; but observation does not usually 
confirm their assertions. 

If the transitory changes supervening in the atmosphere have 
but little influence upon the course of diseases, it is far otherwise 
in regard to the important alterations arising from the succession 
of the seasons : their influence is well established and cannot be 
doubted. Thus, during winter, catarrhs and chronic discharges 
become more severe, pulmonary phthisis advances with greater 
rapidity, chronic rheumatism is more painful, dropsical effusion 
increases more rapidly, and oedema of the lower limbs appears in 
many patients who had never previously presented this symptom. 

The influence of the heavenly bodies upon the course of diseases, 
is, in our climate at any rate, quite as obscure as their action con- 
sidered in the light of a morbific cause. The rising of the Pleiades, 
the Dog-star and Arcturus, the equinoxes and solstices, in no de- 
gree alarm the modern physician, however respectable in other 
ways may be the authority which has pointed out the disastrous in- 
fluence of these periods upon the course of diseases : this opinion, 
however, had several advocates in the times immediately preceding 



PROGRESS OF DISEASES. 239 

our own. Baillou, in the first book of his treatise on Epidemics, re- 
lates the case of a patient who experienced, during an eclipse of 
the sun, an attack of syncope, which continued until the reappear- 
ance of that luminary. Ramazzini states, that in the night of the 
twenty-first of January (this was during the prevalence of epidemic 
petechial fever), when there was an eclipse of the moon, the greater 
part of the patients died, and almost at the very hour when the 
eclipse took place. " Facta per noctem lunari eclipsi, major pars 
(Bgrotantium obiit, ac eadem pent hora qua tiimirum luna labora- 
bat." * Balfour, in Bengal, thought he could perceive that the 
moon had a physical action upon the progress of various diseases.! 
Bruce assures us that he has often noticed, in Sennaar, J the in- 
fluence of this planet upon epileptics ; and the observations of 
Fontana support this assertion ; but all that is known upon this 
point would not serve as foundation for a sound opinion. The 
same may be said in regard to the assertion of certain authors, 
Daquin in particular, that the moon has a positive and constant 
action upon the progress of insanity. M. Esquirol, indeed, has 
also observed that the insane were more excited at the period of 
full moon, but he convinced himself that this agitation was owing 
to the penetration of lunar light into their chambers, for complete 
exclusion of the light was sufficient to prevent the excitement. 

Among those circumstances which influence the course of dis- 
eases, we should bear in mind the greater or less degree of salubrity 
of the patient's residence. Other things being equal, diseases are 
less severe and of shorter duration among isolated individuals; 
the contrary is true in crowded hospitals. This difference is read- 
ily perceived during an epidemic prevailing among all classes ; the 
influence of this cause may be equally well appreciated by a com- 
parison of the success of operations done upon isolated and upon 
hospital patients. 

Climate and the aspect of the dwelling, have also a certain in- 
fluence upon the course of diseases : we refer to our previous 
remarks upon climate and situation, considered as morbific causes. 
The action of heat and cold upon the patient's body, the nature 
and quantity of the food and liquids taken, exercise and rest, very 
powerful sensations, agitation of mind, the passions, and nostalgia, 
are all causes capable of modifying the course of diseases, but 
productive of effects too various for general description. 

In few diseases is the influence of these different agents so re- 
markable as in those of the heart. In these affections, the gravest 
symptoms, such as orthopncEa and infiltration of the limbs, are 
often observed to disappear several times before becoming per- 
manently established : this retrograde course is more particularly 
noticed among poor hospital patients ; in them, the development of 
these symptoms is often determined by errors in diet, but particu- 
larly by fatigue and watching, at a period when the organic lesion 

* Opera. Sydenham, t. ii. p. 54. 

f Journ. de Mddecine, t. Ixvii. 

j Voyage aux Sources du Nil. t. viii. p. 4. 



240 DURATION OF DISEASES. 

alone would not have produced them. By the simple removal of 
these causes, by rest and diet, the disease is reduced within its 
appropriate bounds, and the premature phenomena to which acci- 
dental circumstances had given rise, diminish and even disappear 
for a certain time ; the affection returns to the second or even the 
first stage, after having apparently attained the third. 

There is another condition which has so remarkable an influence 
upon the course of chronic diseases, that we cannot let it pass 
unnoticed ; we mean the state of pregnancy. It not only causes 
the cessation of rheumatic and nervous affections, etc., but also 
seems to suspend the progress of the gravest organic diseases, even 
at an advanced stage. It is observed that phthisis often remains 
stationary in pregnant women ; many of them survive the period 
of parturition and die shortly after. 

Before commencing another subject, we would remark that the 
various circumstances which modify the course of diseases do not 
prevent their exhibiting a striking resemblance, not only in times 
and places nearly related, but also under very dissimilar condi- 
tions. When we read attentively the descriptions of disease by 
observing physicians of every age, from Hippocrates to our own 
times, we must inevitably recognise a great similarity between 
diseases observed in widely separated ages and countries; and not- 
withstanding the difference of climate, manners and other impor- 
tant circumstances capable of modifying them. Baillou and Sy- 
denham in particular, have noticed epidemic fevers similar to those 
described by Hippocrates in the constitution of Thasus, and many 
descriptions by Aretseus of Cappadocia seem models of the dis- 
eases observed in our own times. — M. 



CHAPTER IX. 

DURATION OF DISEASES. 

The duration of diseases (morbi mora) is the period of time 
between their commencement and termination. 

It is not always easy accurately to note the duration of a disease, 
from the difficulty of distinguishing the moment of invasion, and 
also the exact period of its termination ; if there be the least uncer- 
tainty in respect to either of these two periods, the duration can 
only be approximately determined. 

There is still another circumstance which renders this point in 
pathology still more obscure; we refer to the various modes em- 
ployed by physicians in reckoning the days. Some physicians, 
with Hippocrates, reckoned the first day as terminating on the 
night following the attack, at whatever hour it may have been, 
and the following days as included between sunrise and sunset. 



DURATION OF DISEASES. 241 

Others make the medical day to consist of twenty-four hours, each 
day of the disease commencing and terminating at the hour when 
the latter first made its appearance. 

Diseases are extremely variable in their duration ; when lasting 
but one, or, at most, two or three days, they are called ephemeral;* 
they are termed acute, when their duration is not over forty or 
sixty days ; chronic, when prolonged beyond that term. Ephe- 
meral diseases have been divided into ephemeral, properly so called, 
which last but one day, and prolonged ephemeral, which extend 
to the second or third day. Acute diseases have been also sub- 
divided into the very acute {morbi acutissimi), which present grave 
symptoms, and terminate favorably or unfavorably in three or four 
days ; morbi subacutissimi vel peracuti, which continue seven days ; 
acute diseases, properly so called (morbi acuti), whose duration is 
fourteen days; and subacute diseases {morbi subacuti), which last 
from twenty-one to forty days. Chronic diseases have not under- 
gone similar subdivision. These scholastic distinctions are no 
longer observed, and in the more modern schools are hardly under- 
stood, having no practical utility ; the division into acute and 
chronic diseases is the only one generally admitted. 

The duration of diseases varies from a few moments to many 
years. Some fevers last but one day; the Asiatic cholera has 
often terminated fatally in the course of a few hours; there are 
certain haemorrhages which last but a few minutes, and wounds 
of the heart or a large artery may cause instant death. Certain 
rheumatic affections terminate only with the life of the patient. 

There are some diseases whose duration is fixed ; as rubeola, 
scarlatina and variola discreta, when occurring in healthy individ- 
uals ; the specific causes which produce them generally determine 
similar phenomena, succeeding each other in a certain order, and 
ceasing after a fixed time has elapsed. The duration of simple 
wounds and fractures, may be approximately calculated before- 
hand, according to the seat of the injury, age of the patient and 
some other circumstances. The duration of affections produced 
by internal causes is more variable ; that of pleurisy may termi- 
nate in three or four days or be prolonged to thirty, and even 
beyond, when it passes to the chronic state. 

There are certain circumstances which exert a very marked influ- 
ence upon the duration of diseases. Many affections continue longer 
after their second, than after their first, attack. A second ophthalmia 
commonly lasts longer than when it first appears; the same is often 
true of blennorrhagia. This rule is by no means without exception, 
as it is not rare to observe a second peripneumonia, or a second at- 
tack of rheumatism, shorter than the first; in the successive attacks 
of erysipelas, this disease diminishes in duration and severity. 

The treatment and complications also exert a remarkable in- 
fluence, as well upon the duration as the progress of diseases : these 
two points will be hereafter considered. — U. 

* EqitjuiQos; tm, in; tyitQa, day. 

.21 



242 TERMINATION. OF DISEASES. 



CHAPTER X. 

TERMINATION OF DISEASES.* 



ARTICLE FIRST. 

Different Modes of Termination. ( Morlorum eventus.) 

There are some affections which continue through life and are 
not fatal to the patient ; such are certain forms of paralysis and 
chronic rheumatism. Properly speaking, these affections have no 
termination ; but it is otherwise with the majority of diseases, 
which terminate either in the return to health, in death, or in some 
other disease. 

A. The return to health, or the cure (morbi sanatio), consists in 
the complete restoration of all the functions. Its accompanying 
phenomena are exceedingly various, as are the diseases at whose 
close they are observed. Our inability to enumerate them all at 
present, compels us to review them generally, passing from the sim- 
plest to the most complex cases. 

1. Among the diseases confined to one portion of the body, 
haemorrhages and nervous pains are the most simple in their ter- 
mination : the flow of blood is gradually or instantaneously arrest- 
ed, the pain ceases, and the disease is at an end. The case is 
nearly the same in many other affections characterized by one 
predominant symptom, as spasmodic vomiting or nyctalopia : the 
gradual or rapid diminution of such a symptom, is the only phe- 
nomenon presented by the return to health. In the cure of the 
phlegmasia?, the changes are more varied and numerous. Inflam- 
mation of the subcutaneous cellular tissue may serve as an exam- 
ple ; in some cases, the pain, swelling, redness and heat disappear 
by degrees, in succession or simultaneously, and the inflamed part 
gradually regains its previous condition : this is called resolution. 
In other cases, there is purulent secretion, constituting suppura- 
tion ; the enveloping tissues become thin, and finally allow the 
fluid to escape ; in some rare cases, the tumor, at whatever stage 
of development it may be, not excepting that of evident fluctua- 
tion, suddenly disappears, leaving no trace of its existence, except 
flaccidity and wrinkling of the integuments : this is termed reper- 
cussion {delitescence), and is a favorable mode of termination 
in inflammations produced by evident external causes, as burns of 

* We shall add some considerations upon critical phenomena and critical days, 
to the account of the different terminations and principal forms of diseases. 



TERMINATION OF DISEASES. 243 

the first degree, and contusions, but dangerous in those arising 
from internal causes. The phlegmasia? occasionally terminate in 
gangrene, as is observed in furunculus and certain burns ; in the 
former, a rounded eschar, the core, is discharged with the pus ; in 
the latter, there is more or less extensive sloughing of the integu- 
ments ; in both cases, the gangrenous portion is separated from the 
living parts by the pus effused between the latter and the eschar. 
Cicatrization gradually ensues, as in wounds with loss of sub- 
stance. 

2. In general constitutional affections, such as continued fever, 
pestilential diseases, eruptive fevers, etc., the return to health is 
rarely sudden : it is in some exceptional cases only, that in the 
midst of the most violent symptoms, a calm suddenly supervenes, 
which announces the approaching termination of the disease. The 
return to health is most frequently progressive, the functions grad- 
ually regain their healthy action, the countenance reassumes by 
degrees its natural expression, the evacuations are re-established, 
the skin becomes moist, the movements are more easily executed, 
and the patient feels himself improving daily. When the cure 
occurs by means of successive and distinct ameliorations, the 
patient experiences in the space of a few hours, (and often after the 
occurrence of phenomena which had not been previously observed, 
as perspiration or alvine evacuation,) a relief which apparently 
indicates incipient convalescence; but the symptoms, after a degree 
of mitigation, persist with the same intensity for several days, 
until a new amelioration occurs : usually, the second amelioration 
marks the commencement of actual convalescence ; diseases have 
occasionally been observed to persist beyond this point with 
slighter symptoms, and to disappear only after a third or fourth 
effort. 

General affections whose course is periodical, such as intermit- 
tent fevers, and those diseases known by the term masked fevers, 
sometimes terminate suddenly; but more frequently their parox- 
ysms become irregular and incomplete, and the disease disappears 
gradually. 

3. At the decline of local diseases which determine general 
functional derangement, the same phenomena which are mani- 
fested in local and general diseases are simultaneously observed. 
On one hand, peculiar changes occur in the affected organ ; on the 
other, in the functions, whose disturbance was sympathetic. Tn 
pneumonia, for instance, the pain in the side ceases, the respiration 
becomes freer, the cough less frequent ; the sputa, which were 
sanguinolent, are simply mucous, that part of the chest which 
returned a dull sound on percussion, regains its natural resonance, 
and instead of morbid sounds, we hear the gradually returning 
vesicular murmur ; at the same time the face loses its flush, the 
thirst and frequency of pulse diminish, the heat is moderated, the 
skin is soft to the touch and often moist ; the flow of urine is in- 
creased, appetite and strength return, etc. Such are the concomi- 
tant phenomena of recovery it) the principal forms of acute disease. 



244 TERMINATION OF DISEASES. 

In chronic diseases this termination is almost always progres- 
sive : the symptoms, after having increased for some time, diminish 
gradually, so that the transition from disease to a state of health, 
as well as its converse, is usually insensible : this is observed in 
discharges and catarrhs of a chronic nature, in old ulcers, scorbu- 
tus, etc. In certain cases, indeed, we observe chronic diseases come 
to a sudden termination, as in the disappearance of herpetic eruptions 
of long standing, the cessation of leucorrhea, the prompt cicatriza- 
tion of ulcers ; but these rapid cures are very rare in chronic 
disease, and render us anxious in regard to possible sequelae. 

B. The termination in death takes place also in various ways, 
both in acute and chronic diseases. — In the former, it may some- 
times occur suddenly, either from rapid sinking of the vital powers, 
as in abundant haemorrhages, or before exhaustion has reached its 
extreme point, as observed in certain typhoid fevers and in some 
cases of confluent variola ; it may also happen by a kind of as- 
phyxia, or with cerebral symptoms, as convulsions and coma. — 
Death may, at other times, be announced many days previously to 
its occurrence, by a peculiar alteration of the countenance and an 
extreme feebleness in the motions and in the voice ; the tongue 
becomes clammy or dry, deglutition is noisy, difficult or impossi- 
ble; respiration frequent, unequal and rattling; the pulse small, 
weak, intermittent or insensible ; the heat becomes gradually 
extinct from the extremities towards the trunk of the body; the 
body exhales a cadaverous odor, and is partially covered with a 
viscid and cold sweat ; the excretions are involuntary, the sensa- 
tions extinct; the patient differs only from a dead body by retain- 
ing the respiratory movements, which take place at intervals, until 
they cease entirely with life. This state, to which the term 
agony * has been applied, may last for a few hours only, or be con- 
tinued for many days, for one, or even several weeks; its usual 
duration is from twelve to twenty-four hours. — In other cases death 
is preceded and announced by many successive exacerbations in 
the symptoms. This exacerbation of the symptoms in each suc- 
cessive paroxysm, is particularly observed in malignant intermit- 
tent fevers. 

In chronic diseases, the termination in death is rarely sudden; 
sometimes, however, this has been observed in cardiac aneurism, 
or in that of the larger arterial trunks, also in pulmonary phthisis 
and scorbutus ; in all these cases death usually takes place by 
syncope : in chronic pleurisy, when pus is suddenly and profusely 
poured into the bronchial tubes, rapid death by asphyxia may 
ensue. But in most cases, death occurs in chronic diseases by 
progressive exhaustion of the vital energies, the patient being at 
one time reduced to the last degree of marasmus, at another, swol- 
len by serous infiltration into the subcutaneous cellular tissue and 
effusion into the serous cavities. Many such patients retain their 

**Ayiov, a combat. 



TERMINATION OF DISEASES. 245 

intellectual faculties and their appetite to the last ; some sink by- 
degrees, without pain or anxiety as to their fate ; others, in the 
midst of the most excruciating bodily sufferings and the most 
frightful despair. The majority present, three or four days before 
death, a remarkable alteration of the countenance, a state of 
collapse and a leaden hue, which announce to the physician the 
approach of death. 

C. Termination in another disease has been termed by the 
Greek physicians, metaschematismus, * an expression almost bar- 
barous to our ears. Peculiar denominations have also been pro- 
posed, according to the actual transformation of the disease into 
another, or to the mere change of seat or form. In the first case, 
the change supervening in the kind or form of the disease, is called 
diadoche (diadoxis)^ in the second, metastasis % (metastasis), the 
term metaptosis or metastosis§ has been employed in the former 
sense by some, in the latter, by others. Metastasis is the only 
term retained in our language, the others have become obsolete. 
Every displacement or transformation of disease is now called 
metastasis ; the epithets favorable or unfavorable are added, ac- 
cording as the new affection is more or less severe than the former. 

Metastasis takes place frequently in acute, but is more rare in 
chronic, diseases. Rheumatism often terminates by forsaking its 
original seat for an internal organ ; the same is the case with 
haemorrhages : this is metastasis, properly so called, that is, a 
simple change of seat or form, the disease remaining the same; 
while if a haemorrhage or a cutaneous eruption succeed inflamma- 
tion of the stomach or lungs, the disease which replaces the first 
is wholly different: this is the diadexis of the ancients. 

Chronic affections are sometimes observed to cease on the ap- 
pearance of a cutaneous eruption or of continued or intermittent 
fever. M. Sabatier, in a very interesting thesis upon erysipelas, || 
has shown by numerous cases collected at theSSaint Louis Hospital, 
that this exanthema is occasionally followed either by definitive 
cure or by a very favorable change in the course of certain obsti- 
nate eruptions which resist nearly all curative means, as im- 
petiginous eczema, sycosis labialis, mentagra, lichen, and even 
lupus and elephantiasis. 

The transition of the same affection from the chronic to the 
acute state, and vice versa, has been referred to this mode of ter- 
mination. But is not this a simple change in the course of a dis- 
ease, rather than its termination in another? However this may 
be, the substitution of the acute, for the chronic character in disease, 
sometimes effects a cure. It is not, indeed, uncommon to see 

* MtTar t un/uTtriiiitc, transformation or change of form, from ff/^i/u, form, and 
fUTa, signifying a change. 

t JiaSo/l n succession; SiaStxofiai, I succeed. 

t MeTufiTuaig, from iiiTuauM, to transfer. 

§ MfTu/tTcuoij, change of event; from mom, to happen, and utta, signifying a 
change. 

|| No. 209, 1831. 

21* 



246 TERMINATION OF DISEASES. 

urethral discharges persist for months and even years, resisting 
every kind of treatment, and finally be wholly cured when the 
blennorrhea is rendered acute by the influence of some excess or 
by a new inoculation of the virus. 

Diseases arising from internal or external causes, may terminate 
either in death or recovery, but the termination in another disease 
seems peculiar to those produced by internal causes ; for the dis- 
eases which are owing to external causes and exclusively surgical, 
seem incapable of this mode of termination. 

Such are the three modes of termination presented by diseases. 
Upon this point all medical observers are agreed ; it is otherwise 
in regard to understanding and explaining the transition from 
disease to health. We here enter upon the domain of conjecture, 
and, from that moment, must expect to encounter the greatest 
diversity of opinion. 



ARTICLE SECOND. 
Doctrine of Crises. 

$ I. The term crisis * has not been employed in medical lan- 
guage in a strictly uniform sense. Hippocrates declares crisis to 
be present when there is marked increase or diminution of the dis- 
ease, when it degenerates into another, or when it entirely ceases. f 
Some authors apply this term only to the favorable or unfavorable 
changes supervening during the static, or second period of the dis- 
ease ; others make use of it to express a rapid and favorable 
change observed in connection with some new evacuation, or other 
remarkable phenomenon ; others, finally, have given this name to 
the phenomena accompanying the change, and not to that change 
itself. The majority of modern physicians understand the term 
crisis in one of these latter acceptations, which is widely different 
from that given to it by Hippocrates. 

Several varieties of crisis have been admitted ; as salutary and 
fatal, regular and irregular, complete and incomplete. The salu- 
tary are those conducive of recovery ; when prompt and preceded 
by exacerbation of the symptoms, they are crises properly so 
named; they have been designated by the term lysis % (solutio), 
when mild and unannounced by previous exacerbation. Regular 
crises are those ushered in by precursory signs, which occur on 
certain foreseen days, and are accompanied by critical phenomena • 
irregular crises do not present these conditions. Complete crises 

* Est vox hoc, crisis, judicium, hnh too xqiviodai, desumpta a foro judiciali 
quia inter spem vita metumque mortis ancipites tunc agri trepidant, veluti rei coram 
judice; mcerti plane, utrum crimme absolvendi sint, an morte damnandi (Pra- 
ted. Ant Dehaen in Boerhaave. Inst. Path. t. ii. p v!87.) 

f Lib. de Affection. Linden, ii. p. 165. 

| Juoif, solution ; from Uu, I dissolve. 



TERMINATION OF DISEASES. 247 

are those which decide the termination of the disease, by recovery 
or death ; the incomplete leave the patient in a doubtful state. 

The real object of discussion has been the existence of critical 
phenomena, not that of crises. Every one admits changes of 
favorable or unfavorable nature in disease, and the transformation 
of one malady into another ; this we have seen to be the definition 
of the term crisis as used by Hippocrates, but it is otherwise 
with the accompanying phenomena of crisis; great difference of 
opinion exists in regard to their frequency and influence upon the 
termination of diseases. Before examining these two questions, 
we must enumerate the phenomena themselves, and point out their 
antecedent and accompanying signs and the circumstances favora- 
ble to their production. 

A. Critical phenomena may be manifested in various parts. 
They are most frequently observed upon the mucous surfaces ; 
next in frequency is the skin, thirdly the glands, afterwards the 
cellular tissue and serous membranes; some of them may also oc- 
cur in the nervous system.* 

1. The mucous surfaces present certain critical exhalations and 
eruptions. 

The critical exhalations from the mucous surfaces are of several 
varieties ; the natural exhalation may be increased, or may become 
an accidental sanguineous or aqueous exhalation. The mucous 
secretion of the nasal fossae, pharynx and bronchial tubes is some- 
times augmented toward the close of diseases; mucous stools, and, 
occasionally, emesis of glairy matters have been observed at such 
periods ; not unfrequently there is a similar deposit in the urine. — 
Sanguineous exhalations from the mucous surfaces, as epistaxis, 
hasmorrhoidal flux and metrorrhagia have often been observed 
under the above conditions, and considered as critical phenomena. 
But few instances of aqueous exhalation from the mucous surfaces 
have been recorded ; aqueous emesis and catharsis have been 
mentioned, as being apparently critical of dropsy. 

One species only of critical eruption has been observed upon the 
mucous surfaces ; this is the apthous eruption which occasionally 
supervenes in the last stage of acute diseases, especially in children. 

2. The skin likewise presents exhalations and eruptions re- 
garded as critical. In the latter stage of many acute diseases, 
pneumonia particularly, a general perspiration supervenes, which 
is the more remarkable from the fact, that during the first two pe- 
riods the skin often remains dry ; at other times there is only 
slight moisture apparent. — The eruptions observed upon the skin 
toward the termination of acute or chronic diseases, are very nu- 
merous. Erysipelas, furunculus, different species of erythema or 
herpes are the principal ; the latter is most frequently seen upon 

* Dr. Copland differs from our author in his enumeration of critical phenomena, 
in regard to their frequency of seat. He states them to occur, 1st, on the skin ; 
2dly, in the cellular tissue ; 3dly, in the glands ; 4thly, on the mucous surfaces. 
(Med. Diet. Art. Crisis ) — Tkans. 



248 TERMINATION OF DISEASES. 

the lips; pemphigus occasionally appears at the same period; 
Storck* and Morgagni\ have related some very remarkable ex- 
amples. The abundant purulent exhalation produced by vesica- 
tion, and critical icterus, have been placed in the same category, 
although the latter is more appropriately classed elsewhere. 

3. The critical phenomena exhibited by the glandular organs 
may consist in an increase of secretion, or in tumefaction of the 
glands themselves. Salivation was noticed by Sydenham as a 
critical evacuation in certain affections; bilious stools and abun- 
dant flow of sedimentary urine are quite frequent phenomena at 
the decline of diseases. The lacteal secretion, as we have pre- 
viously seen, is critical of milk fever. — Tumefaction of the parotids 
sometimes supervenes on the decline of malignant fevers. Swelling 
of the conglobate glands of the groin or axilla has been considered 
as critical by many physicians who have observed and described 
the plague ; but, in many of these cases, has not a tardily develop- 
ed symptom been mistaken for a critical phenomenon ? 

4. The same may be remarked of the oedematous swelling of 
the cellular tissue, mentioned by Sydenham as a critical phenome- 
non in intermittent fever. % Subcutaneous abscess has also 
seemed critical of certain diseases. — Simple inflammatory swelling 
of the cellular tissue has been regarded as critical in certain cases, 
although suppuration might not have taken place; at the decline 
of fevers a peculiar tumefaction of the extremities, the face and 
even of the whole body, without evident signs of inflammation, 
has been observed. — Gangrene of the cellular tissue and integu- 
ments has been ranked by some authors among the critical phe- 
nomena of adynamic fevers. 

5. The critical phenomena manifested by the serous membranes 
are almost always unfavorable. Occasionally there is dropsy, 
sometimes sanguineous effusion supervening on the decline of 
another disease. The same is the case with synovial effusion into 
articular cavities. 

6. Finally, the nervous system has sometimes furnished critical 
phenomena ; a sharp pain in the course of a nerve, paralysis, or 
convulsion of a portion of the body, loss of a sense, as hearing, 
sight or smell, and even disturbance of the intellectual functions 
have been observed towards the termination of diseases,^ and re- 
garded as critical. 

B. Of the signs which precede and accompany critical phenom- 

* Annus Medicus, ii. p. 112. " Unicus fuit <zger in quo hcec materies intra 
scapulas colligebatur, et fiebat ibi tumor qui magniludine caput virile excessit ; 
aperto tumort, novem libra seriflavi viscidi effluxerunt." 

f De Sedibus et Causis. Lib. iv. art. 7. 

j Opera omnia, t. i. p. 60. 

\ In certain circumstances, violent emotion has arrested the progress of an ob- 
stinate disease, as an intermittent fever or a convulsive affection. Sleep has also 
seemed to banish very severe pains which had continued for many hours. But ad- 
mitting sleep to be a critical phenomenon, it is very certain that strong emotions, 
disconnected with the disease, cannot be so considered. 



TERMINATION OF DISEASES. 249 

en a, there are some which are common to all : there are others 
peculiar to each. 

The common precursory signs are pain, more or less severe, 
often, simple pruritus, heat or a sense of weight in the organ about 
to become the seat of the critical phenomena ; to these may be 
added a notable increase of the general symptoms of the disease, 
especially the force and frequency of the pulse. The usual con- 
comitant signs of critical phenomena are a sensation of amend- 
ment, more or less decided, and a perceptible diminution in most 
of the symptoms. 

Critical phenomena are not always announced by peculiar signs ; 
those which present them most frequently, are the alvine evacua- 
tions, haemorrhages, the urine and the sweat. 

The signs preceding alvine discharges are borborygmi, colic, 
distension of the abdomen, eructation and flatulence, a sense of 
tension in the lumbar region, pains in the thighs and knees, and a 
somewhat irregular pulse. The evacuation takes place without 
pain ; it is copious, homogeneous, of a yellow or brownish color, 
pultaceons and, sometimes, mucous. 

Critical epistaxis is usually announced by redness, with slight 
tumefaction of the face and eyes; occasionally the redness and 
swelling are limited to one of the alas nasi, the one corresponding 
to the nostril whence the blood will flow. A dull pain in the fore- 
head, at the root of the nose or at the nape of the neck, throbbing 
of the temporal arteries, tinnitus aurium, deafness, luminous 
spectra, involuntary tears, and, in certain patients, slight delirium or 
somnolency, precede epistaxis. A quick, hard pulse and frequent 
respiration have sometimes announced this phenomenon ; epistaxis 
should be copious to be termed critical. 

Haemoptysis is preceded by a sensation of heat in the chest, and 
by embarrassed respiration. 

The signs indicative of hsematemesis are praecordial anxiety, 
eructations, and all the precursory phenomena of vomiting. Has- 
matemesis and haemoptysis, as also hasmaturia, are almost always 
unfavorable critical phenomena. 

The hsemorrhoidal flux is announced by pain and sense of 
weight about the sacrum, tenesmus, and sometimes dysuria. The 
same precursory signs belong to metrorrhagia, with occasional 
augmentation or diminution in volume of the mammae, hypogas- 
tric colic, and, for each female individually, the addition of the 
phenomena usually preceding her menstrual periods ; these vary 
in different persons. 

Critical diuresis is preceded by a sense of weight in the hypo- 
chondria, dull tension in the hypogastrium, titillation in the urinary 
organs, and diminution of cutaneous exhalation ; frequent excretion 
of urine afterwards takes place ; it is copious, usually high colored 
when cool, and deposits a cohesive, homogeneous, white or rose 
colored sediment. The addition of nitric acid sometimes throws 
down a white, abundant, albuminous precipitate. 

Sweating is frequently preceded by slight chills, diminished 



250 TERMINATION OF DISEASES. 

urinary and faecal excretion, and occasionally by flushing of the 
face; the elevation of the hypochondria and slight pruritus of the 
cutaneous surface have been mentioned as signs of this phenome- 
non. We have not enumerated, among these various signs, the 
alterations in the pulse peculiar to each kind of crisis, because 
experience has not confirmed the ingenious assertions of Sola?w 
and his followers. Physicians have also been as prompt in aban- 
doning, as they were ready to admit, the doctrine of critical pulse.* 

* Borden, the most celebrated historian of critical pulse, divided the pulse into 
irritative or non-critical, which is contracted, sharp, hard, dry and quick ; and into 
critical pulse, which is bounding, full, strong, frequent and often unequal. The 
latter is met with in the third period of diseases, the former in the first. The 
critical pulse is divided into superior and inferior: the former indicates that the 
crisis will take place by some organ situated above the diaphragm ; the latter, that 
it will occur in one below it. 

" The superior pulse is remarkable for a rapid reduplication of the arterial pul- 
sations : this reduplication, which is its essential constituent, seems originally to 
be but a single pulsation ; it is liable to intervals from time to time ; these are 
longer or shorter, more or less frequent, according to the nature or degree of the 
disease. Dilatation, usually effected in one, occupies two beats, and there are two 
sensible efforts succeeding a natural contraction of the artery. 

'• The inferior pulse is irregular, that is, its pulsations and intervals are unequal : 
the intervals are sometimes so considerable as to constitute actual intermittence, 
according to the kind of inferior pulse and in proportion as it may be more or less 
marked. A sort of leaping of the artery is sometimes noticed, which serves in 
some degree to characterize this species of pulse. 

" The superior and inferior pulse maybe simple, compound or complicated: 
they are si?nple when they indicate the approach of crisis by a single organ ; com- 
pound, when the critical effort is about to be manifested in several at once ; compli- 
cated, when they are united at intervals with the irritative pulse, during which 
time the critical effort seems interrupted." 

The different characteristics of the simple pulse are as follows : 

Superior Pulse. 

1. Pectoral. " This is soft, full, dilated ; its pulsations equal ; in each of them 
a sort of undulation is noticed, that is, the dilatation of the artery takes place in 
two beats, but with an ease, softness and gentle oscillatory force, which do not 
allow us to confound this kind of pulse with the others." 

2. Guttural. " Strong, with redoubling of each beat ; less soft and full, often 
more frequent, than the pectoral, it is apparently intermediate between it and the 
nasal pulse." 

3. Nasal. ''Redoubled beat like the guttural, but fuller and harder; much 
stronger and quicker." 

Inferior Pulse. 

1. Stomachal. " Announces vomiting, and is the least developed of all the 
varieties of critical pulse : it is less unequal than any of the kinds of inferior pulse ; 
the artery seems to stiffen and tremble beneath the finger ; it is often somewhat 
leaping in character ; the pulsations are frequent, and take place at moderately 
equal intervals." 

2. Intestinal. " More developed than the former; the pulsations quite stTong, 
as if rounded, and above all, unequal, as well in their force as in their interval, 
which is very easily distinguished, since it happens almost constantly, that after 
two or three quite equal and elevated pulsations, there occur two or three less de- 
veloped, less prompt, nearer together, and as if communicating with each other ; 
from this results a sort of leaping or convulsive effort (' explosion de V art ere') 
of the artery, of greater or less regularity : to the irregularities of this pulse very 



TERMINATION OF DISEASES. 251 

The other critical phenomena have not, generally speaking, pe- 
culiar precursory signs ; in those cases only where critical abscess 
terminates a disease, the urine is sometimes observed to remain 
clear, and transient chills and partial sweats are noticed at the 
decline of the disease. * 

At one time a single critical phenomenon only is observed, as 
copious haemorrhage or profuse sweating ; at another, many are 

remarkable intermittence is often added. It is never so full and developed as the 
superior pulse : its intermittence does not necessarily follow a definite order, on the 
contrary, its disorder renders it easy of recognition." 

3. Uterine. " Usually more elevated and more developed than the natural 
pulse : its pulsations unequal ; the rebounding character is, it is true, less constant, 
less frequent and decided than in the nasal pulse, but is still sufficiently percepti- 
ble." 

4. Hepatic. "The most concentrated after the stomachal; neither hard nor 
resistant ; unequal, its inequality consisting in the succession of three or four 
unequal pulsations to the same number perfectly equal, and which often appear 
natural." 

5. Hemorrhoidal. " Unequal, like the other species of inferior pulse ; but the 
inequality is peculiar to it. The pulsations have little similarity in force, and still 
less as to interval. When less unequal, they seem almost always to belong to the 
state of irritation : there are, however, occasionally, some which are fuller, and in 
which the contracted character is not so perceptible : when more dilated, they are 
soon followed by a rebounding pulse. Three or four rather concentrated pulsa- 
tions, sharp, resistant and nearly equal, are succeeded by two or three somewhat 
dilated, as if rounded and less equal ; the three or four following pulsations are 
rebounding in their character; but these different pulsations have this in common, 
that there constantly exists a sort of tremor, greater frequency and depth of con- 
traction than in the other varieties of inferior pulse: a depth, so to speak, is per- 
ceived in the pulsations, which, with the tremor, is the most distinguishing char- 
acteristic between the uterine and hemorrhoidal pulse." 

6. Urinal. " Unequal, with a sort of regularity : there are several pulsations 
gradually diminishing in force even to the point, we might almost say, of disap- 
pearing beneath the finger, and recurring in the same order from time to time : 
the pulsations in the intervals are more developed, sufficiently equal and slightly 
leaping in their character." 

Sudatory. " When the pulse is full, pliant, developed, and strong; when in 
addition to these modifications, the pulsations become unequal; when they in- 
crease to the last, which is distinguished by a dilatation and at the same time by a 
more decided suppleness than in the other pulsations, a critical sweat should 
always be expected." 

* Hippocrates assures us that when the urine continues transparent and crude 
for a long time, other signs being favorable, we should suspect abscess in some of 
the organs below the diaphragm. (Praenot, No. 78, Foes). The case of Pithi- 
on, related by Hippocrates in the third book of his Epidemics, is not the only one 
confirmatory of this assertion, however extraordinary it may appear. Ttssot has 
given us another in his description of the bilious fever of Lausanne, and we have 
ourselves seen a similar case in a patient at La Charite. He was affected with 
peripneumonia, in the latter stage of which the urine remained constantly trans- 
parent, after all the symptoms had completely disappeared. He seemed convales- 
cent, when upon the seventeenth day there supervened severe pain in the left leg. 
On the nineteenth day, this pain became throbbing in its character and remarkable 
tumefaction and hardness were added. Afterwards, the pain and swelling in- 
creased and extended to the thigh ; but on the fifth day, the urine, hitherto trans- 
parent, became turbid and ammoniacal, and the inflammation, which threatened 
suppuration, terminated promptly in resolution. 



252 TERMINATION OF DISEASES. 

met with simultaneously ; in certain cases, all the eolatoria seem 
open at once; the skin is covered with sweat, there is profuse flow 
of urine, the bowels become relaxed, the mucous secretion of the 
nasal fossae and of the air passages is increased, etc. At other 
times, various critical phenomena take place, but successively. 

C. Critical phenomena are not in all circumstances equally evi- 
dent. They are more distinct and frequent in youth and infancy, 
in persons of strong constitution, in temperate climates, in elevated 
situations, and in the spring of the year; they are more obscure 
in the diseases of the aged, in feeble constitutions, in moist situa- 
tions, and under the influence of an active treatment. Baglivi 
asserted that they were less frequent among the inhabitants of 
cities than among those of the country ; and others have noticed 
their greater frequency in the higher classes. 

There are certain circumstances favorable to the production of 
particular critical phenomena. Critical haemorrhage is more fre- 
quent in the spring and in dry summers, in fertile countries, and 
in those of sanguine temperament who are subject, when in health, 
to habitual haemorrhage ; it is chiefly observed from the age of 
fifteen to thirty-five. Exhalation from the mucous surfaces takes 
place especially in those of lymphatic temperament, in wet seasons, 
as autumn and winter, and in low and marshy grounds. Critical 
diarrhoea has seemed to be more frequent in adults of bilious tem- 
perament, and in autumn ; critical diuresis, in the lymphatic, has 
been more often noticed in winter and spring. 

If the reports of some distinguished physicians may be credited, 
it would seem that each country imparts to disease a peculiar ten- 
dency to certain critical phenomena. Coray, in his erudite notes 
to the treatise upon the atmosphere, water, and regions, assures us 
that critical sweats are more frequent in Italy and in warm coun- 
tries generally ; that in Holland and England, urinary deposits 
are quite common ; that in western France the miliary eruption is 
more frequently critical of diseases, while at Paris critical phe- 
nomena would he more varied. 

It has been thought that there are some critical phenomena 
which more especially belong to diseases of certain cavities. M. 
Voisin, in a thesis read before the Parisian Faculty of Medicine, 
asserts that thoracic affections terminate most frequently by criti- 
cal phenomena which are manifested upon the cutaneous surface, 
while cerebral affections usually terminate by alvine evacuations. 
This opinion, founded upon a certain number of observations and 
upon the sympathy which exists between the lungs and the skin, 
and between the head and the abdomen, demands the attention of 
medical observers. 

D. The duration of critical phenomena is variable ; the majority 
persist for twelve or twenty-four hours only ; critical diaphoresis 
and diuresis usually continue into convalescence, and their un- 
seasonable suppression often induces recurrence of the disease. 



TERMINATION OF DISEASES. 



253 



Haemorrhages sometimes continue for a few minutes only, while 
certain eruptions appearing at the decline of diseases, have per- 
sisted, in some cases, for several months. 

If, after the enumeration of these various phenomena, cited by- 
authors as critical, we would determine to what extent they de- 
serve this appellation, we are compelled first to examine their 
frequency, and afterwards their influence upon the course of dis- 
eases. 

There is great difference of opinion among writers upon this sub- 
ject; and, first, in regard to the frequency of critical phenomena ; 
some asserting them to be exceedingly rare ; others, that they are 
constantly present whenever treatment or a deteriorated constitu- 
tion do not prevent. Authorities and arguments have been accu- 
mulated on all sides, in order to solve a question which facts alone 
can decide ; the numerous essays published upon this subject have 
only rendered the proposed end more remote. We do not pretend to 
decide a question so long disputed, but shall confine ourselves to the 
simple exposition of the result of our observations and reflections. 

We remark, in the first place, that this question does not seem to 
us so important as it has been considered, and the neglect into 
which it has now fallen, confirms, to a certain extent, this opinion. 
However this may be, the following is our opinion in reference to 
the frequency of critical phenomena. In very many acute diseases, 
and especially in inflammations of moderate intensity, we are not 
in the habit of employing any of those active means which have 
been regarded as peculiarly suited to prevent the development of 
critical phenomena, and we are compelled to state that in an im- 
mense majority of cases, we have seen these diseases cured with- 
out any signification of their resolution by remarkable phenomena ; 
we cannot consider a slight moisture, more abundant or more 
loaded urine, or certain alvine evacuations, as critical phenomena ; 
we regard them as such only when they draw the attention by 
something unusual in their nature or intensity, something, in short, 
which distinguishes them from the common symptoms of these 
diseases. It is, however, in exceptional cases only, that such phe- 
nomena have been observed, and in a great majority of cases, 
whatever may have been the treatment, the diseases have seemed 
to us to terminate favorably or unfavorably without critical phe- 
nomena of importance. 

In regard to the second question, which refers to the influence 
exerted by critical phenomena upon the result of diseases, a major- 
ity of the old writers considered these phenomena the cause of the 
re-establishment of the functions ; * that the morbific matter, prop- 
erly elaborated, was excreted with the urine, the sweat, the faeces, 
etc., and that the disease terminated in this manner by the elimi- 
nation of its productive and continuing cause. This opinion has 

* Critical phenomena may also correspond to an exacerbation of symptoms, or 
even to the death of the patients ; but the term is usually employed in a favorable 
sense. 

22 



254 TERMINATION OF DISEASES. 

been, latterly, disputed by very distinguished physicians, who 
have considered the phenomena occurring at such times as the 
simple effect of the re-establishment of functions previously dis- 
turbed or suspended. We shall point out the principal reasons in 
favor of these two conjectures. 

Those who see in critical phenomena, and especially in critical 
evacuations, the cause of re-established health, offer many argu- 
ments in support of their opinion. 1. According to them, the epoch, 
at which these phenomena appear, proves that they are the actual 
cause of the return to health, since they often precede amendment, 
and are, in many cases, announced by peculiar signs, while the 
disease is yet at its height. 2. The relief which succeeds these 
critical phenomena, and the reappearance of the disease when 
they are unseasonably suppressed, favor the above opinion. 3. 
These phenomena cannot be considered the effect of the re-estab- 
lishment of the functions, if we remember that they differ very 
much from those presented during health : the evacuations at the 
termination of disease are never similar to those of health : the 
urine contains sediment ; the copious and general sweats exhale a 
peculiar odor ; the faeces are abundant and pultaceous, etc. 4. 
Can haemorrhage, abscess, pustules and apthae, supervening on the 
decline of acute diseases, be considered as the effect of the re-estab- 
lishment of the functions alone 1 Assuredly, there is here some- 
thing more than the cessation of morbid phenomena. 5. If these 
various proofs, united, were still insufficient, it cannot be denied 
that the occurrence of the catamenia, during the fever preceding 
their first appearance, and the secretion of milk, in that following 
parturition, are, incontestibly, the causes which arrest the func- 
tional disturbance. 6. If, in certain cases, the course of nature is 
obscure, (add the partisans of this doctrine,) such are not the 
circumstances suitable for its study : when the veil that shrouds 
it is less impenetrable, the mechanism of its action may be detected. 

Those who have considered the phenomena occurring at the 
decline of diseases, as the effect, and not the cause of the return 
to health, found their opinion upon arguments of considerable 
plausibility : 1. The phenomena termed critical are generally 
observed in one class of diseases only, viz. the acute diseases : 
moreover, it most frequently happens that they are wanting, as is 
proved by the statements of even Hippocrates and Forestus, which 
are cited by the partisans of crisis : but if these phenomena were 
essential to the termination of the disease, would they not be of 
constant occurrence 1 2. The so called critical phenomena do not 
always appear previous to or at the same time with the amend- 
ment ; they often succeed it, and must then be considered the effect, 
and by no means the cause, of the change which has supervened. 
The precursory signs which announce these phenomena, besides 
being of very rare occurrence, do not prove them to be actually 
critical : delirium, which is but a symptom of disease, has its own 
precursory signs. 3. The same phenomenon which may be con- 
sidered unfavorable or valueless in one case, is regarded as favor- 



TERMINATION OF DISEASES. 255 

able in another, and this at different periods in the same indi- 
vidual : the sweats, for example, which take place throughout 
the disease, are considered unfavorable during the first, indifferent 
during the second, and useful in the third stage; is it not more 
natural to admit that they are, in all the periods, but one of the 
symptoms of the disease, and not a phenomenon distinct from the 
others and capable of modifying its course ? 4. Most of the critical 
evacuations differ very little from the natural : if some exhibit a 
greater dissimilarity, the difference should doubtless be attributed 
to the former malady, and to the still existing disturbance of the 
functions, which only gradually recover their complete regularity. 
5. In regard to diseases which appear at the instant when others 
terminate, as unusual haemorrhage, exanthemata, etc., it may hap- 
pen, either that the appearance of the one class and the cessation 
of the other are only a coincidence, or that the first of these phe- 
nomena may be the cause of the second. Supposing the latter 
proposition to be true, it would be proved that one disease might 
suspend another ; but would that prove that the sweats, the sedi- 
mentary urine, etc., produce a similar effect? 6. If relief follow 
the appearance of critical evacuations, and if the exacerbation or 
return of the symptoms be produced by their suppression, they 
are not thereby proved to be the cause of this change. Suppres- 
sion of natural evacuations, may excite in a healthy person the 
development of any disease whatever ; is it surprising that the 
same cause should produce analogous effects in one who is debili- 
tated, and cause recurrence of an affection but just terminated 1 

By an impartial examination of all the circumstances which 
favor these two opposite opinions, we see how difficult it is, if we 
would not decide hastily, to adopt the one and reject the other. 
The partisans of critical phenomena will always cite, in support of 
their doctrine, the lacteal secretion, which, in the newly delivered, 
seems, indeed, the cause to which the cessation of the antecedent 
fever must be ascribed ; but if we afterwards consider the course 
of reasoning, and the facts upon which the contrary opinion is 
founded, its entire rejection will be found difficult. 

The insufficiency of each of these theories might perhaps lead to 
their reconciliation, although they are in complete opposition. If 
we observe the various resources of nature, and how rarely she 
is limited to an exactly uniform course, we might be induced to 
think that the same phenomena are at one time the effect, and at 
another, the cause, of the re-establishment of the functions. It is 
even possible that the phenomena observed at the declining period 
of diseases may have relations with those preceding and succeed- 
ing them, which escape our observation. We should not be hasty 
in drawing general conclusions, still less so, in assigning bounds 
to the powers of nature. 

Crises, in Hippocratic language, being only remarkable changes. 
either favorable or unfavorable, supervening in the course of dis- 
eases, their existence cannot be doubted. 

This is not the case with critical phenomena, whose influence 



256 TERMINATION OF DISEASES. 

upon the termination of the disease, is, and always will be, exceed- 
ingly obscure. 

In some few cases, these phenomena seem to play an active part 
in the resolution of the disease ; analogy would lead us to suppose 
that the same might be true in many other cases, where their in- 
fluence is less evident. 

The greater number of acute diseases, however, terminate with- 
out critical phenomena, and the phenomena which have been dig- 
nified with this name, are, for the most part, nothing but new 
diseases, which have supervened upon the decline of the first, or 
the tardily developed symptoms of the original disease, or lastly, 
the simple effect of the re-establishment of previously suspended 
secretions. 



ARTICLE THIRD. 
Doctrine of Critical Days. 

Do crises, that is, the favorable or unfavorable alterations su- 
pervening in the course of diseases, take place exclusively, or par- 
ticularly, on certain days, or indifferently upon any? Are there, 
or not, critical days 1 

This doctrinal point has long been a permanent topic for contro- 
versy in the schools. Its partisans and their opponents have been 
drawn, as is almost always the case, by the heat of debate, beyond 
the point which they wished to defend or attack. The former 
have thus been led to assert that disease could not be terminated 
except on certain days, while the latter maintain that no disease 
whatever is restricted in its termination to any particular day. 

The following is the doctrine of Hippocrates in reference to criti- 
cal days. 

He regarded the latter days of each week, or period of seven 
days, as most favorable to the changes which occur in disease. 
These days are the 7th, 14th, 20th, 27th, 34th, and 40th : he 
termed them critical days. Counting in this manner, the third 
septenary period commenced upon the last day of the second, that 
is, the 14th day ; the sixth week commenced upon the last day of 
the fifth, or the 34th ; so that three periods, of seven days each, 
consisted of only twenty days, and six periods comprised but forty 
days. Hippocrates, therefore, reckoned twenty-one medical days in 
twenty solar days. Chesneau, in his Treatise on Fever, proposed 
a medical day of twenty-three hours ; but this would not be ex- 
actly that of Hippocrates, which is somewhat shorter. 

Hippocrates placed those days which occur in the middle of the 
septenary periods, in the second rank, as the 4th, 11th, and 17th; 
he named them indicatory, because, in his opinion, the alterations 
are rather indicated than declared, upon those days : they are in- 
dicated either by some new phenomenon, or by diminished or aug- 
mented intensity of the disease. 



TERMINATION OF DISEASES. 257 

The remaining days were divided into intercalary, upon which 
the crises happen less frequently, and are less complete than upon 
the critical and indicatory days, and into vacant or non-decretory 
days, upon which crisis rarely occurs. The days appertaining to 
each of these four series are as follows : — 

Critical days, 7th, 14th, 20th, 27th, 34th, 40th, 60th, etc. 
Indicatory days, 4th, 11th, 17th, 24th, etc. 
Intercalary days, 3d, 5th, 6th, 9th, etc. 
Non-decretory days, 2d, 8th, 10th, 12th, 13th, 15th. 

Our idea of the doctrine of Hippocrates upon critical days would 
be incorrect did we consider it as exclusive. This great physi- 
cian had the wisdom to offer nothing upon this subject as being of 
constant occurrence ; he supposed that the course of diseases was 
modified according to season and epidemics. The observations 
recorded in his works are not always conformed to his general 
axioms upon critical days, and this alone would prove that he ad- 
mitted exceptions. He also thought that crises might be advanced 
or retarded a day, taking place, for instance, upon the 6th, or even 
the 8th, which is a non-decretory day, instead of on the seventh. 

Galen and his followers were far from imitating the circum- 
spection of the father of medicine ; they disfigured his theory by 
asserting that certain days were constantly favorable, and others 
always unfavorable; so that no disease could terminate unfavora- 
bly upon the 7th day, nor favorably upon the 6th. Upon this 
subject Galen calls to witness the immortal gods, who, says he, 
know the truth of my words ! 

It is as easy to refute the exclusive assertions of Galen, as it is 
difficult to combat the reserved doctrine of Hippocrates. If there 
be a certain number of affections, which may terminate indifferently 
at any period, there are many others whose cessation, in a fixed 
time, is constant, and which have, as has been remarked, a kind 
of maturity comparable to that of the vegetables; variola and 
typhus, particularly, are of this class. Of forty-eight cases of grave 
fever recorded by Forestns, thirty terminated upon critical days, 
eight upon indicatory days, and ten only upon the vacant or inter- 
calary days. By collecting all the observations scattered through 
the works of Hippocrates, Dehaen has shown that in one hundred 
and sixty-five cases of acute disease, one hundred and sixteen 
complete or incomplete crises took place upon critical, or indica- 
tory days, and seventy-seven only, upon other days. Favorable 
crises have occurred most frequently upon critical or indicatory 
days, the unfavorable, upon intercalary, or vacant days.* 

This influence of the critical days is not evident in internal dis- 
eases alone ; it would seem from the observations of Testa, that it 
extends, in a certain degree, to surgical affections. According to 
this author, it is usually upon the 4th, 7th, Uth, 14th, or 20th 
days that remarkable alterations take place in wounds, that ab- 

* Dehaen, Pralect : in Boerhaave. Inst. Path. t. ii. p. 276. 
22* 



258 TERMINATION OF DISEASES. 

scess discharges itself, that favorable evacuations, and the acci- 
dents of disease, particularly convulsions, supervene. 

The opponents of the doctrine of critical days have asserted that 
it was not observation which led Hippocrates to its establishment, 
but that he was prejudiced in favor of the numerical system of Py- 
thagoras. Celsus, in particular, thus indirectly reproaches Hippo- 
crates, when he accuses the old physicians of having referred the 
periods of disease, and the critical days, to the power of numbers. 
When we reflect upon the circumspection with which Hippocrates 
expresses himself in regard to the influence of critical days, we 
find it difficult to reconcile language so reserved with such a pre- 
judice as has been mentioned. If we compare the numerical doc- 
trine of Pythagoras with that of the critical days of Hippocrates, 
we shall be still more convinced that the latter was not blinded by 
Pytha gorism. The attentive perusal of the writings of Hippocrates 
does not allow us to suppose that he attached so much importance 
to numbers in general, and to unequal numbers in particular, as 
has been generally believed. The doctrine of critical days, as pre- 
sented in his authenticated works, is so different from that con- 
tained in the books incorrectly attributed to him, that it becomes 
concurrent proof in showing the slight foundation that exists for 
the distinction which has been made. 

We shall not go so far as to assert that the researches of Hippo- 
crates upon critical days are wholly foreign to the system of 
Pythagoras ; but it is another thing that this system suggested to 
Hippocrates the idea of critical days, or that this physician was 
led by that system to observe them ; if, therefore, it be proved that 
the numerical doctrine, and that of critical days, although to a cer- 
tain extent analogous, differ in many respects; if, as would be 
easy to show, they are, in many points, in complete opposition, it 
cannot be admitted that the doctrine of critical days is only the 
application of the system of Pythagoras to the course of diseases, 
and we are forced to the conclusion that Hippocrates relied mainly 
upon his own observations in announcing a doctrine, the idea of 
which might have been suggested to him by the numerical system. 

Most of the discussions which have arisen concerning critical 
days, might have been avoided if the point in debate had been 
better understood, and each disputant had clearly expressed to what 
extent he wished to question or defend this opinion. Almost all 
these partisans willingly agreed that diseases did not undergo re- 
solution in every case, without exception, upon critical, or indica- 
tory days, and, very probably, the majority of their opponents 
would have admitted that there are certain days upon which the 
changes in diseases are somewhat more frequent ; from that mo- 
ment the question would no longer have turned upon the relative 
frequency, and the observations subsequently made, with the in- 
tention of elucidating this latter point, would have had at least the 
advantage of enriching the annals of science, even if they left this 
question undecided ; for it is peculiar to exact observations, that, 
even when they fail to attain the observer's object, they remain 



CONVALESCENCE. 259 

forever, useful monuments for consultation, and suitable aids in the 
solution of the questions daily arising by reason of the progress of 
medicine. 

Before terminating this article, we would remark that the doc- 
trine of critical phenomena, and that of critical days, are, to a 
certain extent, independent, and that one may be well founded, 
and the other not. 

In conclusion, we would add, that the doctrine of critical days, 
like that of critical phenomena, does not possess the importance 
which has been attributed to it ; that the difficulty of fixing the 
days of the invasion and termination of diseases, renders it inap- 
plicable in many cases, and that it allows both the adherents and 
antagonists of this theory to interpret the same facts to their ad- 
vantage. — M. 



CHAPTER XI. 

CONVALESCENCE. 

Convalescence (convalescentia) is an intermediate state between 
disease, which no longer exists, and health, still unrestored : it 
commences when the characteristic symptoms of the disease have 
disappeared, and terminates at the period when that free and 
regular functional action, constituting health, is fully re-established. 

The term convalescence consequently supposes a certain degree 
of gravity in the antecedent disease. After simple indisposition, 
or the cure of certain local affections, there is no convalescence. 

Convalescence has been divided into the real and the fallacious : 
this division cannot be admitted. If disease persist after a marked 
remission, the individual is yet ill ; if it have ceased, he is conva- 
lescent. Convalescence may be uncertain, but is never fallacious. 

The phenomena of convalescence necessarily vary, like those of 
the antecedent disease. They have, however, certain points in 
common, both in acute and chronic affections. 

In the latter, the slowness with which the re-establishment of 
the functions takes place, constitutes the principal character of 
convalescence : the countenance long retains the impression of 
disease ; the healthy standard, as regards flesh and strength, is not 
regained for several months ; the appetite languishes for a long 
time, the stomach and intestines are inactive. An entire year 
often elapses before complete recovery is attained ; and in certain 
persons, especially those of advanced age, the system experiences, 
for an indefinite period, the effects of the powerful shock it has 
received. 

The phenomena which accompany convalescence from acute 
disease, are far more numerous and remarkable. One of the first 



260 CONVALESCENCE. 

effects of the cessation of disease is a rapid emaciation of the 
whole body, particularly of the face, which becomes paler. This 
emaciation and pallor seem especially connected with the cessation 
of the febrile action, and with the diminution of heat ; for even in 
the living body, heat determines an increase of volume in its con- 
stituent parts, an actual rarefaction of the solids and fluids ; the 
re-establishment of the secretions during the third period, has also 
a certain influence in diminishing the volume of the body. At the 
same time that the convalescent experiences relief from the cessa- 
tion of his pain or uneasiness, his loss of strength becomes more 
evident : it is with tottering steps and great effort that he first 
attempts to walk ; his voice remains for some time feeble, and 
regains by degrees only, its natural tone. This prostration extends 
likewise to the intellectual faculties: imagination, memory and 
judgment, it is true, are freely exercised by the majority of indi- 
viduals ; but violent mental exercise induces instant fatigue, head- 
ache or other morbid phenomena. It is also observed that the 
convalescent state is accompanied by remarkable increase of the 
nervous susceptibility ; convalescents, although inclined to agree- 
able thoughts, are impatient and irascible, and physical and moral 
impressions often cause them a shock out of proportion to the 
determining cause and the usual impressibility of the patients. 

The regular action of the digestive functions is but gradually 
resumed ; the tongue continues slightly coated, appetite does not 
always return promptly ; wine often has a bitter taste, and bread 
is tasteless; thirst diminishes or ceases; in the majority of cases, 
appetite returns more quickly than the powers of digestion, and 
this is the cause of the attacks of indigestion so frequent among 
the convalescent : some persons, however, eat, and digest with 
ease, a considerable amount of food, from the first day of conva- 
lescence from grave disease. We have observed two convalescents 
from typhus fever take, without injury and at one meal, upon the 
very day of the cessation of the disease, more than half a pound 
of solid food. Hildenbrand has made analogous observations : he 
relates that the appetite often amounts to actual voracity. * Cos- 
tiveness is usually noticed during convalescence from acute disease ; 
sometimes, on the contrary, there is diarrhoea. Respiration is easy 
while the person is at rest, but exercise and conversation cause 
dyspnoea. The pulse often remains frequent for many days ; but 
if all the other signs are favorable, this frequency need not alarm 
us ; it should not deter the physician from allowing the convales- 
cent the food they request. In certain persons the pulse becomes 
slower than in the healthy state, owing, doubtless, to the rest and 
long continued diet required by the disease : there may be but 
fifty, or even fewer pulsations in a minute. Most convalescents 
experience palpitations, even from the slightest causes, as walking, 
or from the effect of a lively sensation or emotion ; these are, how- 
ever, by no means alarming; in the ansemic, a bellows' sound is 

* Typh. Contag. Trad, de Gasc. p. 86. 



CONVALESCENCE. 261 

usually heard in the heart and large arteries: in almost all cases 
the lower limbs swell readily, when the upright position is long 
maintained, and in the evening slight oedema is perceived around 
the ankles. Convalescents are habitually cold, even in the warm 
season, either because their natural heat is diminished, or because 
a prolonged continuance in their apartments, and in bed, has ren- 
dered them more susceptible to external cold. In very many, the 
cutaneous transpiration is abundant during sleep, and the secretion 
of urine is also increased. The grayish color of the fseces, often 
noticed, and the infrequency of their discharge, lead us to suppose 
that the biliary secretion is diminished at the commencement of 
convalescence. 

One of the most remarkable phenomena of convalescence, is the 
excitement of the generative organs, causing strong venereal desire, 
lascivious dreams, and nocturnal pollutions. Many authors relate 
that old men who had not had any ejaculation for years, have 
experienced it during convalescence. The menstrual discharge 
frequently does not recur for many months after the cessation of 
the disease. 

To the above phenomena, we shall add the desquamation of the 
cuticle and the loss of the hair, which occur in many individuals 
at a very advanced stage of convalescence. These phenomena 
are often observed after grave diseases, and especially after those 
accompanied by an eruption upon the skin, even if obscure, as in 
typhoid fever. The hair, when renewed, has not its original color 
or form, and from this arises its peculiar appearance in convales- 
cents from severe disease. 

To finish the picture of convalescence, we should mention the 
feeling of comfort, which is more and more lively in proportion to 
the completeness of the restoration, and those new delights tasted 
by the convalescent in the simple performance of the most ordinary 
acts of life ; delights unknown to one who has never been ill. " No 
one," said Hildenbrand, "has experienced pleasure in perfection, 
if he has not felt that which arises during convalescence ..." 
Indeed, it is only when we have been deprived of health, as of any 
other enjoyment, that we can really appreciate it. 

The duration of convalescence is often uncertain, because the 
epoch of its commencement and termination are not well defined. 
It can hardly ever be accurately determined; its proximate duration, 
only, can be known. 

Many conditions, moreover, may prolong or abridge convales- 
cence. The age and constitution of the individual, the nature and 
duration of the affection, the treatment, dwelling, season and reg- 
imen, are those most influential in determining the time which will 
elapse between the termination of the disease, and the complete re- 
covery of health. Other things being equal, convalescence is shorter 
in infancy and youth ; it is longer in persons habitually feeble and 
indisposed ; in damp situations, in those where the houses are 
below the level of the ground, and in hospitals, than in opposite 
circumstances. The ingestion of unwholesome food, too rigorous 



262 CONSECUTIVE PHENOMENA. 

diet, or the opposite extreme, prolong the period of convalescence. 
It has likewise been observed to be shorter in spring than in 
autumn and winter. Finally, it is of very constant occurrence, 
that it is generally shorter after inflammatory diseases, than after 
those accompanied by great prostration. Excessive evacuations, 
(especially the sanguineous,) either spontaneous or artificial, occur- 
ring in the course of a disease, prolong convalescence. 

When we attentively observe the changes which supervene dur- 
ing convalescence, we generally remark a daily increase in the 
regularity of action and freedom of the various functions ; but we 
notice that the recovery does not take place with like uniformity 
and promptitude in the different organs. Not only are those which 
were primarily and principally affected generally the last to 
recover their energy, but among those secondarily affected, a 
certain number do not regain their normal state for some time 
after the others. Convalescence is a complex phenomenon ; it is 
composed of the partial re-establishment of each of our organs : it 
may be complete in one patient, while it has hardly commenced in 
another. 

Established convalescence does not always lead to an immedi- 
ate and complete recovery of health : it may be impeded in its 
course by certain phenomena which are not of sufficient severity 
to constitute a morbid condition ; it may be interrupted by the 
recurrence of the disease which preceded it. These two points in 
the history of disease will be examined in the two following chap- 
ters. — M. 



CHAPTER XII. 

CONSECUTIVE PHENOMENA. 



By the words consecutive phenomena, are denoted those various 
disturbances of the functions which continue, or make their first 
appearance, after the natural termination of diseases. They are 
sometimes confounded with the phenomena of a prolonged conva- 
lescence, but, in general, are widely different, not only in degree, 
but because, for the most part, they affect a single function only, 
while convalescence is distinguished by a general debility affecting 
alike all the organs of the economy. 

One of the most familiar examples of a consecutive phenome- 
non, is the yellow color of the integuments which sometimes con- 
tinues after the causes, which have produced any obstruction to the 
secretion or excretion of bile, have ceased to act, as is apparent 
from the entire re-establishment of the digestive functions, the 
normal color of the urine and faeces, and the perfect regularity of 
all the functions ; the icterus, in these cases, is no longer a symp- 



CONSECUTIVE PHENOMENA. 263 

torn, since there is no disease. The impregnation of the integu- 
ments by the coloring matter of the bile, is the persistent effect of 
a morbid condition which has ceased to exist ; it is not the sign 
of a present disease, but only the consequence of a disease already 
terminated; and this icterus, which, at the time of its first appear- 
ance, was included among the symptoms, properly so called, is now 
but a consecutive phenomenon. 

Of these consecutive phenomena, some are contemporaneous 
with the disease, as for example, pain in the side in cases of pneu- 
monia ; others appear a certain number of days after the com- 
mencement, but a considerable time before the termination, of the 
disease. An instance of the latter, is the yellow color of the skin, 
which shows itself after seven or eight paroxysms of intermittent 
fevers, and which continues for a greater or less time after conva- 
lescence. There are others which make their appearance when 
the disease begins to abate, and on this account have been consid- 
ered by many physicians as critical phenomena ; and, finally, there 
is still another class of these phenomena which are only known to 
exist after complete recovery, as the oedema which follows a great 
number of diseases. 

It is apparent from this brief classification, that the consecutive 
phenomena of diseases are very numerous and of various descrip- 
tions ; we only propose, however, in the following pages, to give an 
enumeration of the principal ones that come under our observation. 

Many persons experience, after sickness, a remarkable dimi- 
nution or increase in the size of the body. In the first case. 
instead of recovering their natural embonpoint, they continue to 
lose flesh, in the same manner as during sickness ; in the latter, of 
which Tissot saw many examples, they discover an alarming ten- 
dency to obesity. In other cases of convalescence, the patient is 
left with a debility which affects the movements of the whole body, 
or particular parts of it, and sometimes with a trembling, more or 
less general. Hoarseness of the voice continues after some cases 
of angina and certain nervous affections. Pains are very common 
consecutive phenomena after herpes zoster and other phlegmasia?. 
The organs of sense, particularly those of sight and hearing, re- 
main oftentimes enfeebled after the other functions are completely 
re-established. Delirium was observed by Hippocrates, and Piquer 
saw two examples of it. We have also ourself observed it. Entire 
sleeplessness is also a common consecutive phenomenon. Tissot 
thinks that this may be owing, in some cases, to the loss of habit. 
Sometimes we see various disorders of the digestive functions, 
such as loss of appetite, weakness of the stomachic digestion, and 
constipation so obstinate as to resist the most energetic treatment. 
Cough, hiccup, and frequency of the pulse, sometimes remain after 
the other functions have recovered their natural exercise. Exces- 
sive perspiration and abundant flow of the urine, are two phenom- 
ena that often appear after acute diseases, and one or the other 
almost invariably. Sometimes they occur alternately until the 
health is completely re-established. Their suppression is liable to 



264 RELAPSE AND RECURRENCE. 

be followed by an increased exhalation in the cellular tissue, and 
the supervention of anasarca. 

To the consecutive phenomena above enumerated, may be added, 
abscesses, gangrene and hectic fever resembling phthisis. These, 
however, are rather diseases, than simple consecutive phenomena. 

Consecutive phenomena may increase or diminish in intensity, 
or remain stationary. They are various, also, in as far as they 
possess sometimes a continuous and sometimes a periodic charac- 
ter. The pains which follow herpes zoster, the dyspnoea which 
follows pneumonia, are continuous like those affections. On the 
other hand, the phenomena which remain or make their appear- 
ance after periodical diseases, have the same periodical character. 
Thus after intermittent fevers, we observe phenomena differing 
with regard to form and duration, and making their appearance at 
intervals corresponding to the attacks of the fever, as a momentary 
chill of the whole, or any part of the body, transient heat, a pain 
or spasm, and a brick colored sediment in the urine. Phenomena 
are sometimes observed, however, after diseases of this sort, which 
have not this periodical character. Of this class, are the swelling 
of the spleen, ascites, and the oedema of the lower extremities, 
which continue for a greater or less time after intermittent fever. 

We can lay down no general rule with respect to the duration 
of consecutive phenomena. Generally speaking, however, they 
do not continue above two or three weeks, though sometimes 
longer. The weakness or stiffness of limbs, which sometimes fol- 
lows rheumatic affections, has been known to continue during 
life.— 0. 



CHAPTER XIII. 

RELAPSE AND RECURRENCE. 

By the term relapse is signified the renewal of a disease during 
the period of convalscence ; by recurrence (morbus recidivus), is 
understood the reappearance of a disease after the complete restor- 
ation of health. 

Relapse is commonly produced by some occasional cause : ex- 
posure to cold, an error in diet, excessive exercise, a violent emo- 
tion, immoderate use of medicine, are the most frequent causes 
of the return of a disease. 

Relapse is not of equal frequency in all affections ; there are 
some diseases, as the contagious eruptive fevers, in which it 
never takes place; there are others, as peripneumonia and pleu- 
risy, in which it rarely occurs ; and finally, still others, as inter- 
mittent fevers, in which it is of frequent occurrence. The fre- 
quency of relapse in the latter affection has been attributed to the 



RELAPSE AND RECURRENCE. 265 

course of these fevers, which have a marked tendency to repro- 
duce themselves, and to the kind of habit the economy seems to 
have contracted, when the paroxysms have been many times re- 
peated. A remarkable circumstance connected with the relapse of 
intermittent fevers, is their almost uniform occurrence at the day 
and at the hour, when the fever should have appeared, had not 
the paroxysms been suspended. Strack remarked that he had 
sometimes seen this regularity in the recurrence of fevers, after the 
lapse of several months and even a year ; but the latter cases are 
very rare, and may admit of doubt ; for however little the parox- 
ysm be advanced or retarded, how can the application of the cal- 
culation to so considerable a lapse of time hold good 7 

The symptoms accompanying relapses are nearly the same with 
those of the primary affection. There is generally, however, more 
debility, which may increase the danger. Their duration is ordi- 
narily longer, and when the life of the patient is spared, they 
generally leave him in a state of debility, from which he recovers 
but slowly, and, in some cases, never regains his strength. But 
to this assertion there are numerous exceptions ; thus, the reappear- 
ance of erysipelas after a lapse of seven or eight days from the ter- 
mination of the first attack, and in the part previously affected, is 
rarely so violent as at first, being of shorter duration, and, in some 
cases, only ephemeral. 

Relapse should not be confounded with the new diseases which 
sometimes attack the convalescent, nor with recurrence. 

The latter is occasioned sometimes by a peculiar predisposi- 
tion, and sometimes by a fresh exposure to the occasional or spe- 
cific causes of the disease. So great is the tendency of rheumatism 
to recur, that but few cases have been cited of persons who have 
suffered but once in their lives from this disease ; the recurrence 
in such cases appears to be owing to predisposition. So with 
erysipelas of the face, which frequently reappears in some individ- 
uals at longer or shorter, and sometimes determinate, intervals, 
many examples of which are related by Lorry and Franck. The 
case is otherwise in the yearly recurrences of intermittent fevers in 
marshy places ; these are owing to a fresh exposure to the specific 
cause of the disease. 

The affections in which relapse never occurs, are also exempt 
from recurrence, with some few exceptions ; yellow fever and 
typhus, for example, are never developed twice in succession, but 
may reappear after a greater or less period. In rheumatic affec- 
tions, relapse is, perhaps, less frequent than recurrence. 

The symptoms of recurrence present nothing remarkable ; they 
are not constantly more violent, or lighter, than in the primary 
affection. A second, a third pneumonia is sometimes more violent 
than the first; but the contrary is often observed. We saw a man 
at La Charite, who was suffering from peripneumonia for the 
tenth time; the first inflammation had been severer than those 
that followed. In the first attack of erysipelas of the face this dis- 
ease has been so violent as to endanger the patient's life, after- 
23 



266 GENERA, SPECIES AND 

wards diminishing in severity in proportion to the number of times 
it reappeared, becoming at last so slight as to produce but little 
functional disturbance, and to last but a short time. What we 
have said of erysipelas, equally applies to many other diseases, 
particularly angina tonsillaris. — O. 



CHAPTER XIV. 

GENERA, SPECIES AND VARIETIES OF DISEASE. 

The number of diseases to which man is liable is very great, 
and would be infinite, if we considered, as distinct diseases, the in- 
numerable varieties of the same disease that come under our obser- 
vation. The same affection is, perhaps, never presented twice 
under the same form. 

If facts had been considered isolated from each other, and those 
among them which are analogous had not been distinguished, 
science would never have existed. The relation of facts to each 
other, the resemblance observed between many of them, and their 
union under a common name, indicate the commencement of med- 
ical science, and it is only at this stage that we can arrive at any 
knowledge of the course of diseases and the means of treating them 
with success. 

It is natural to suppose that the genera of diseases recognized 
by the earliest observers, were very different from those of the 
present day, particularly as regards internal diseases. Doubtless 
they often mistook the symptom for the disease, considering as dif- 
ferent affections what are merely different phases of the same 
affection, and confounding under the same denomination diseases 
totally distinct in their nature. 

In proportion, however, as physicians have become enlightened 
by experience and observation, numerous modifications have been 
successively made of the genera originally admitted. Considered 
merely in this aspect, the study of pathological anatomy has ef- 
fected an entire revolution in medicine. Physicians of the present 
day, however, are far from having arrived at the same conclusion 
with regard to the genera of diseases, and in fact have not even 
attempted to establish principles upon which this division can be 
founded. We shall endeavor to supply this deficiency. 

Among diseases, there are those that consist in a material and 
perceptible lesion of the solids or fluids that enter into the compo- 
sition of the human body ; there are others in which we can dis- 
cover no perceptible alteration, and still a third class in which 
there are only variable lesions. 

Well defined lesions of an organ, as a fracture of a bone, a 
wound of an integument, a burn, etc., constitute diseases of a well 



VARIETIES OF DISEASE. 

marked character. The same remark may be made with regard 
to some other lesions, the development of which is spontaneous, 
such as inflammations, cancer, tubercles, etc. It is true, that in 
each of these affections the material lesion is not precisely the same 
in every stage of the disease, but the changes which it undergoes 
are the same, and repeated observation only proves their regular 
succession and invariable connection. The redness of skin, which 
marks the commencement of many of the eruptive diseases, is a 
very different lesion from the pustules that are developed at a 
later period, and these differ no less, in their turn, from the thick 
crusts by which they are succeeded. Here, however, and still 
more clearly than before, there is but one disease. Tn typhoid 
fever, the anatomical lesions are different in each of the three 
periods of the disease. At its commencement the patches are hard 
or soft, prominent, and of a rosy white color ; afterwards eschars 
and ulcerations make their appearance, and still later in the pro- 
gress of the disease, the surface of these ulcers becomes clean, 
their edges become depressed, and they cicatrize and present a slate 
color. Here, again, there is but one disease, because these lesions 
depend upon one cause, and succeed each other in a determinate 
order. 

The presence of foreign bodies in the interior of the organs, 
whether inanimate, as calculi of different kinds, or living, as 
cysts which participate in the general vitality, or parasitical ani- 
mals, which have an entirely independent existence, constitutes 
many distinct genera of disease. 

Collections of fluid in the interior of the organs, attended with no 
perceptible lesion of the solid tissues, form well defined genera of 
disease. Such are the effusions of serum and blood in the serous 
membranes and the cellular tissue. These effusions, it is true, 
often follow lesions of the solids, but since the accumulation is 
oftentimes the only material alteration which is perceptible, the 
accumulation must in such cases constitute the disease. The same 
remark extends to those cases in which certain fluids are excreted 
in excessive quantities, and often with some change in their quali- 
ties, as, for example, the urine in diabetes and Bright's disease. 
In certain haemorrhages, the effusion of blood from the vessels 
which naturally retain it, is equally a single perceptible lesion. 

Sanguineous plethora and anemia may also be classed among 
diseases in which there exists a material perceptible lesion. The 
diminution in the quantity of the blood in anemia has been meas- 
ured with great exactness, and its increase in cases where there 
are symptoms of general plethora can hardly be called in question. 

Diseases arising from specific causes form also distinct genera. 
The sting of the bee, the cutaneous affection that follows contact 
with the nettle, the bite of the viper, the virus of variola, vaccinia, 
rubeola and scarlatina, syphilis and glanders, and poisons of every 
kind, give rise to a distinct class of affections, in which the mate- 
rial lesion, whatever it may be, is only a secondary phenomenon. 
It is. in fact, in these cases, the cause that constitutes the disease. 



268 GENERA, SPECIES AND 

Intermittent fevers, in the production of which malaria plays so 
important a part, are, as a general rule, a well denned class of dis- 
eases. If their symptoms, type, and the specific action of quinine 
in their treatment, evidently distinguish them from other diseases, 
should we not refer this resemblance of their phenomena to the 
identity of their cause ? 

With regard to those diseases in which there is no material 
lesion of the organs, and which arise from no specific cause, as the 
nervous diseases, we can only establish their genera from an exam- 
ination of their symptoms. Upon this subject the greatest differ- 
ence of opinion has existed among physicians down to the present 
time, and we cannot safely form conclusions in regard to it, until 
we have a more thorough knowledge of the causes which produce 
these affections and the lesions of which they consist. A great 
number of them have already been found to be connected with 
organic lesions upon the existence of which they evidently depend. 

But whatever the genus of a disease may be, it is not always 
developed with the same symptoms, attended with the same suc- 
cession of phenomena, protracted to the^ame duration, or inclined 
to the same termination. Variola, for example, is always accom- 
panied by an eruption siti generis, which cannot be mistaken ; but 
the general phenomena of this affection, and the number and form 
of the pustules, are exceedingly various. In one case, the pulse is 
full, the temperature of the body increased, the pustules round, 
distended and surrounded by a red areola; in another, on the 
contrary, the pulse is feeble, the skin almost cold, the eruptions 
feeble, of a brownish color, and with a pale or livid areola. In 
some cases, the eruption is rare and scattered nearly uniformly 
over the whole skin ; in others, the pustules run together over the 
whole, or are collected in great numbers on some part, of the body. 
Sometimes the disease is attended with no danger ; at other times 
the danger is imminent, and in a third class of cases death is almost 
inevitable. Now would it be possible to acquire a correct idea of 
variola by studying it only under one of the numerous forms 
which it assumes? Undoubtedly not; and we may apply the 
same remark to the study of every disease. 

It is then essential in pathology to understand thoroughly the 
different modifications of each disease. These modifications, how- 
ever, are not all equally important. Some of them are so slight 
that they may be entirely disregarded, while others, it is useful, 
and even indispensable, to distinguish. These latter have been 
divided into two classes ; in the first class have been placed those 
of, apparently, a greater, and in the second, those of a less, degree 
of importance. To the former class the term species has been ap- 
plied, and to the latter, the term varieties, although even at the pres- 
ent day no fixed rule has been established for distinguishing the one 
from the other. The word species has not the same signification 
in pathology, as in botany and zoology. In these sciences, it 
designates the assemblage or class of individuals that perpetuate 
themselves by reproduction ; while the word varieties comprises 



VARIETIES OF DISEASE. 269 

those individuals which, though differing somewhat in appearance, 
can reproduce, under given circumstances, individuals resembling 
those from which the variety derives its origin. In pathology, the 
word species expresses a mere abstraction. Its distinction is so 
vague and indefinite, that some have admitted twice, and even 
four times, the number that have been admitted by others. Sau- 
vages carries the number as high as eighteen hundred ; Sagar, to 
two thousand five hundred; while Cullen admitted only six hun- 
dred. There is hardly an instance, as Bayle * has remarked, in 
which the same author has published several editions of his works 
without modifying, in some respects, the species that he had for- 
merly admitted. 

If it is impossible, as we have reason to believe it is, after the 
fruitless efforts of nosologists, to obtain a definition of species 
which shall be a uniform rule applicable to all diseases, we should, 
nevertheless, in making such a distinction as we can, have regard 
to the objects of the greatest utility, and determine the species of 
the disease from the circumstances that exercise the greatest in- 
fluence on its treatment. In all the acute phlegmasia, there is, 
according to us, the inflammatory, bilious, adynamic and ataxic 
character, which ought to determine their species, because the 
character of a disease, considered with reference to its treatment, 
is as important as, and sometimes more so than, its genus. What- 
ever the genus of a disease may be, if it is attended with the gen- 
eral symptoms of inflammatory fever, we resort to blood-letting 
and the antiphlogistic regimen; if it has an adynamic character, 
we must have recourse to stimulants and tonics ; if it is legitimate, 
that is to say, if it is accompanied with the general phenomena, 
only, which are peculiar to it, without any of the features which 
characterize inflammatory or adynamic fevers, &c, repose and 
a slender diet are most generally the only conditions necessary to 
its cure ; even these are not always indispensable, as in some cases 
of erysipelas, chronic catarrh, etc. The division of the inflam- 
mations into the acute and chronic species is no less important, 
considered with reference to their treatment, than the preceding. 
"With regard to haemorrhages, their division into two species, the 
active and passive, has the advantage of the same practical char- 
acter; but since there are many haemorrhages that belong to neither 
of these species, it is necessary to recognize a third species which 
can hardly be confounded with the others. This division is also 
applicable to fluxes, effusions, and particularly dropsy, and may be 
extended with advantage to certain nervous affections. The 
happy effect of tonics, which have been used for a long time, seem 
sufficient to prove the existence of passive neurosis ; and the 
extraordinary cures that have been effected in other cases by a 
totally opposite course of treatment, in addition to other circum- 
stances, would induce us to recognise the existence of active neu- 

* Theses de la Faculte, Annee, 1801, No. 71. 
23* 



270 COMPLICATIONS. 

rosis. There are, doubtless, cases ; however, which belong to 
neither of these two classes. 

The modifications that take place in the symptoms of those 
diseases termed organic, with the consequent changes of treatment, 
are unimportant, and constitute rather varieties than species unless 
they are connected with some peculiar diathesis, as a scrofulous, 
scorbutic or syphilitic taint.* 

Varieties of disease are the result of a multitude of circumstan- 
ces some of which are of practical importance, as, for example, 
the general severity of the disease, the predominance of any par- 
ticular symptom, or the appearance of any remarkable epiphenom- 
enon, and also the various peculiarities relative to seat, extent, 
cause, type, etc. The number and form of the pustules in variola, 
the seat of the exanthema in erysipelas, the severity of the pain 
in pleuropneumonia or of the delirium in typhoid fever, constitute 
varieties. The same may be said of the continuous or remittent 
progress of continuous diseases ; of the quotidian, tertian or quar- 
tan type of periodic diseases, etc. We recognise varieties, also, in 
diseases according as they arise from external causes, or are pro- 
duced by an internal disposition, as they are fixed or movable, as 
they affect external or internal parts, the limbs and trunk, or the 
organs more or less essential to life. Varieties of diseases are 
sometimes referable, also, to the manner in which they terminate, 
to their regular or irregular return, etc., and they frequently result 
from complication. — O. 



CHAPTER XV. 

COMPLICATIONS. 

The word complication, in its most extended meaning, expresses 
the mingling together of many different things, of which it may 
be important to ascertain the presence and determine the nature. 
In pathology, we understand by complication, the concurrence or 
simultaneous existence of many diseases capable of exerting a 
mutual influence on each other. The coexistence of many entirely 
independent, diseases, as, for example, cataract, calculus in the 
bladder, and an external injury, is not a complication. Some phy- 
sicians f have proposed to limit still farther the meaning of this 

* The division of diseases into false, (morbi spurii, nothi), and true {morbi 
exquisiti, legitimi), has been properly rejected by physicians of the present day. 
The classification into these species has been entirely exploded by recent nosology. 

f Fernel and Plempius, two physicians of the sixteenth and seventeenth cen- 
turies, divided diseases into solitary and multiple, {morbi solitarii et multiplices). 
They subdivided solitary diseases into simple and compound. They termed a 
disease simple, which affects one or more parts of the body in the same manner ; 
as, for example, pneumonia confined to a single viscus, and gout which attacks at 



COMPLICATIONS. 271 

word, and to apply it only to diseases which exist simultaneously 
in the same organ, and concurrently produce a disturbance of the 
same function ; but their opinion does not carry with it the weight 
of authority. 

Some authors have fancied that they traced the influence of 
complication even in the most trifling cases of disease, while others 
have been almost wholly unwilling to recognize its existence. It 
becomes important, then, to establish some principles by which we 
may be guided with regard to a subject, which, though not of the 
greatest importance, is certainly not destitute of interest. 

1. The simultaneous development or consecutive extension of the 
same disease, of a phlegmasia, for example, or an organic lesion 
in continuous or contiguous parts, is not sufficient to constitute a 
complication. The simultaneous inflammation of the pleura, the 
parenchyma of the lungs and the bronchial membrane, is obviously 
the extension of one disease to different tissues, and not three 
diseases. So in surgery, the injury of the integuments that cover 
the seat of a fracture is never regarded as a complication. A 
cancerous affection of the pyloric extremity of the stomach is also 
a simple disease, although the disease extends to the lymphatic 
glands, the epiploon, the pancreas or the liver. 

2. The simultaneous existence of similar lesions in organs, more 
or less remotely situated from each other, does not constitute a 
complication, when these lesions result from the same cause. 
Thus the tubercular or cancerous affection of different organs in 
different parts of the economy is a simple disease, because one 
cause, however latent, has given rise to these multiple lesions. 

3. The simultaneous existence in different parts of the body of 
lesions differing entirely from each other, is insufficient to constitute 
a complication, when these lesions are owing to the influence of 
one ascertained cause. We may mention, as examples of this, the 
sore throat which sometimes accompanies variola, the swelling of 
the lymphatic glands of the neck in cases of tinea, and the develop- 
ment of ulcers, excrescences, exostoses and buboes, in cases of 
syphilis. 

4. Neither is a complication the coexistence of two diseases, 
one of which is a necessary consequence of the oilier. Of this 

the same time different articulations, but which arises from one cause, and is fol- 
lowed by the same results. They termed those diseases compound which, though 
possessing the characteristics of single diseases, arise from a concurrence of dif- 
ferent causes ; such are the adynamic or bilious phlegmasia;. 

They recognized three sorts of multiple diseases. 1. Complicated diseases, 
(morbi impliciti, complicati) , those that exist at the same time in the same organ, 
and concurrently produce a disturbance in the same function, as, for example, 
pneumonia and phthisis. 2. Connected diseases (morbi connexi vel consequentes) , 
those cases in which one disease concurs in the production of another ; such are 
peritonitis accompanying inflammation of the uteius, and gangrene developed in 
the integuments in severe cases of fever. 3. Distinct or separate diseases (morbi 
disjuncti vel separati), those that do not affect the same function, and exert no in- 
fluence in the production of each other ; two wounds, one of the thigh, the other 
of the head, the simultaneous existence of gout in the feet and lipoma in the 
thorax, or of ulcers in the leg and pneumonia, are obvious examples. 



272 COMPLICATIONS. 

class of cases is peritonitis, resulting from a perforation of the 
intestines or stomach, and rarer examples of it are those cases of 
pleurisy which follow the ulceration of the pleura in consequence 
of the softening of a pulmonary tubercle. 

5. Lastly, the general 'phenomena that accompany the affection 
of certain organs, do not constitute a complication. In cases of 
this sort there is but one affection, although the general disposition 
of the patient gives the local disease a peculiar modification, as 
for example, in bilious or adynamic pneumonia. 

It follows, in the first place, that a complication cannot exist 
except when there is a coexistence of diseases entirely distinct from 
each other, either as regards their origin and the mode of treatment 
proper for their cure, or their seat and the anatomical lesions of 
which they consist ; and, in the second place, it is also a necessary 
condition, as we have before remarked, that these diseases be not 
entirely independent, but capable of exerting a mutual influence 
on each other. 

The number of diseases that may exist at once in the same in- 
dividual and form a complication is unlimited. It is rare, how- 
ever, to see more than two. We sometimes meet with cases where 
an individual is affected with five or six different diseases ; but 
these cases are very uncommon, and, besides, in a greater part of 
them the diseases have an entirely independent existence, and con- 
sequently come under the head of coexistence, and not of compli- 
cation. 

The causes of complication are very various. Sometimes each 
disease arises from a specific cause, as in a complication of two 
eruptive fevers. Sometimes the same occasional cause develops 
two distinct affections. Thus, the effect of cold may give rise, in 
the same individual, to a rheumatic affection and a pulmonary 
catarrh, although, in cases of this sort, there is reason to suspect 
the concurrent influence of predisposition. Complications are not 
equally common in all conditions of life. They appear to be of 
more frequent occurrence in infancy and mature age, than during 
the intermediate period, and in the inhabitants of cities, rather 
than those of the country. 

The most important point to consider, in the examination of this 
subject, is the influence which complicated diseases exercise on 
each other. In some cases, the supervening disease diminishes 
or increases the severity of the primary affection, and in others 
has the speedy effect of, either temporarily or permanently, sus- 
pending its symptoms. Acute diseases are sometimes observed 
to affect in this manner chronic complaints, to arrest which, all 
the resources of art have been in vain resorted to. Incipient 
variola has been known to be suspended by the development of 
rubeola and on the termination of the latter, to make its reappear- 
ance. A visceral phlegmasia that follows an injury almost inva- 
riably modifies the symptoms of the external v/ound, and the nature 
of the fluid which it exhales. Erysipelas, which is developed in 
oedematous limbs, often terminates in the suppuration of the cellular 



DIAGNOSIS. 273 

tissue and the gangrene of the integuments. In another class of 
cases, the supervening disease does not influence the one that 
precedes it but is influenced by it. Examples of this are cases of 
accidental wounds and fractures in persons afflicted with scurvy. 
The scorbutic affection undergoes no perceptible change, but the 
fractures do not unite, and the wounds assume the appearance 
peculiar to scorbutic ulcers. 

We conclude, that wherever many diseases exist simultane- 
ously; 1. they may either have no influence upon each other; 2. 
the second disease may modify, suspend or terminate the first; or 
3. the first, may aggravate the character of the supervening, dis- 
ease. — O. 



CHAPTER XVI. 

DIAGNOSIS. 

Diagnosis* is that part of pathology whose object is the discrim- 
ination of diseases. To discriminate a disease is to recognize it 
whenever it exists, whatever be the form it assumes ; and also to 
decide that it does not exist, whenever other diseases appear with 
symptoms similar to its own. 

"The science of diagnosis" says Louis, in his Memoir upon 
fungous tumors of the dura mater, " is the most important, most 
useful, and most difficult of all the divisions of medical science. 
The discrimination of the peculiar nature of each kind of disease, 
and of its different species, is the source of curative indications. 
Without an accurate and precise diagnosis, theory is ever at fault 
and practice often unfaithful." 

There are two different modes of considering diagnosis ; succes- 
sively, in single diseases, or by abstraction of particular cases, as 
a branch of general pathology. The latter only will occupy us at 
this time ; the former belongs to the special description of disease. 

Diagnosis, thus generally considered, presents many points of 
importance; of these the principal are, I. the signs upon which 
it should be founded ; 2. the conditions necessary for its formation, 
both on the part of the patient and the physician ; 3. the proper 
mode of examination and interrogation of the sick, in order to 
acquire a knowledge of the affections under which they labor ; 4. 
the component elements of diagnosis, viz. the seat and nature of ana- 
tomical lesions, and the form and type of symptomatic phenomena ; 
5. the circumstances rendering diagnosis difficult or uncertain. 

§ I. Diagnostic Signs. — The term diagnostic signs comprises 

* Jiuyvoois, discernment; dta, through (thoroughly,) ynwoxw, to know. 



274 DIAGNOSIS. 

all those circumstances which enlighten us in regard to the genus 
or species of a disease ; the principal are, past or present symp- 
toms, the predisposing or determining causes of the disease, its 
mode of access and progress up to the moment of examination, and 
the effect of remedial measures. Diagnostic signs are not all of 
equal importance ; those termed characteristic, are such as either 
alone, or united, are sufficient for the recognition of the disease ; for 
example, the sense of tension, pain in the ahdomen, vomiting, 
etc., attending peritoneal inflammation. These signs have also 
been called true, essential, sufficient, univocal, because they leave 
no doubt in regard to the existence of the disease. Among these 
latter signs there are some known as pathognomonic* it being 
affirmed that the disease never exists without them, and that they 
are never present except the disease exist. Characteristic, differ 
from pathognomonic, signs, in this respect, that the disease may be 
manifested without the former, but never without the latter. But, 
as has been correctly remarked, if the term pathognomonic be em- 
ployed in so rigorous a sense, no sign would deserve the appella- 
tion. The mobility of the fragments in fracture of the bones, and 
the flow of blood in haemorrhage, are not pathognomonic signs, 
because both fracture and hsemorrhage may occur without these 
symptoms. For this reason most modern authors have employed 
the terms pathognomonic and characteristic without any distinction, 
to designate the signs clearly indicating the existence of disease. 
Other signs, known as common, equivocal, insufficient, are those 
met with in many diseases, but appertaining especially to none ; 
such are frequency of the pulse, elevation of temperature and 
thirst. These signs are not indifferent in diagnosis, but are less 
important than the preceding. 

The signs perceived by the physician's own senses have an en- 
tirely different value from those derived from the account of the 
patient and his attendants. It is mainly by the aid of the former 
that he should form his opinion ; the latter will often mislead him 
if he yield them his entire confidence. 

Finally, there are positive and negative signs in disease, that is, 
the absence of certain phenomena and the existence of others, may 
concur in deciding the physician's opinion. Negative signs, how- 
ever, are of far less value than those which are positive ; thus, fine 
and dry crepitus, sanguinolent sputa, vomiting of dark colored 
matters and epigastric tumor, are signs of pneumonia and cancer 
of the stomach ; the absence of these signs does not prove that the 
lung is not inflamed, nor that the stomach is free from scirrhus. 

We consider it needless to enlarge farther upon the diagnostic 
signs of diseases ; it has already been our duty in various parts of 
this work, and particularly in the long chapter devoted to symp- 
tomatology, to point out the diagnostic value of very many; we 
shall again find it necessary to notice them at a future time, when 
speaking of the different modes of exploration necessary for the 

* Uu6og, disease j yrwuovty.bg, pertaining to discrimination; yocoaxtu, to know. 



DIAGNOSIS. 275 

formation of diagnosis, of the form and type of symptomatic phe- 
nomena, or, finally, of the conditions which render diagnosis diffi- 
cult. Whatever we might add in this connection would belong to 
the particular history of disease. 

§ II. Necessary Conditions for the Formation of Diagnosis 
on the part of the Patient and Physician. — There are many 
conditions on the part of the patient, which, if not indispensable 
in forming a diagnosis, are, at any rate, well suited to render it 
more easy and exact. The first is, sufficient intelligence to 
understand the questions proposed by the physician, and to 
answer them with precision. We see how difficult it is to form 
a decided opinion in regard to a patient, when his intellectual fac- 
ulties are naturally obtuse or accidentally disturbed, when he is too 
young to express himself verbally, or when we do not understand 
his language. Another important condition is the absence of all 
attempts at deception on the part of the patient, either by conceal- 
ing certain circumstances relating to his disease, or by stating 
symptoms which he does not experience. There are some patients 
whose intelligence is sufficient, and who do not intend to deceive 
the physician, but who render their examination very embarrass- 
ing by the manner in which they describe their sensations and 
answer the questions proposed to them. Instead of simply stating 
their sufferings, and replying directly to questions, they give their 
opinion of the peculiar nature of their disease; one is tormented 
by mucous discharges, bile, the blood, or by an acrimonious state 
of the humors; another has irritation, tension, or relaxation of 
the nerves, etc. It is easy to conceive that when a patient has 
expatiated for an hour or more upon his sensations, constantly 
dwelling upon the biliary and mucous secretions, the acrimonies, 
and the nerves, the physician will have made no progress in the 
diagnosis. We might suppose that by requesting patients not to 
use such language, but only to tell what they actually feel, we 
could induce them to speak more intelligibly ; but we are en- 
tirely mistaken ; the greater number do not change their language 
in the least. The physician needs all his patience to enable him 
to listen ; and in certain cases he is obliged to form his opinion 
solely by what he sees, almost entire abstraction being made of all 
that he has heard. 

The necessary conditions for accurate diagnosis on the part of 
the physician, are numerous. The first, and indispensable condi- 
tion, is a thorough knowledge of pathology. He who is not fa- 
miliar with the signs of all diseases is not fit to give an opinion of 
any one in particular. Another condition, no less important than 
the theoretical knowledge of disease, is long and careful observa- 
tion, and ability, by means of frequent dissections, to confirm 
or rectify a diagnosis made during the progress of disease. The 
physician who has not for a long time applied his knowledge at 
the bedside and assisted at many post-mortem examinations, is 
certainly unfit to form a correct opinion of the diseases he observes. 



276 



DIAGNOSIS. 



Supposing his diagnosis to be correct in some cases, it would be 
the opposite in a great number, and in all, it would be formed 
slowly and doubtfully. Skill in diagnosis, which constitutes, in 
connection with a readiness to perceive indications, that quality 
known as medical tact, can only be acquired gradually ; it implies 
the union of all the qualities necessary to the observer ; integrity of 
the senses, which thus distinctly transmit every modification of the 
phenomena within their jurisdiction, a firm and penetrating mind, 
capable of properly collating, comparing with discernment, and de- 
ducing from facts the inferences and consequences which they fur- 
nish, and which, uniting boldness and prudence in due propor- 
tions, dares at times to obey the dictates of a seeming inspiration, 
which is really an accurate, although a rapid, appreciation of the 
most expressive phenomena of the disease. These precious quali- 
ties are rarely combined in one individual, and the number of phy- 
sicians remarkable for great skill in diagnosis is always very 
limited. 

There is still another condition, which, if not indispensable, is at 
least of great service to the physician in the diagnosis of diseases ; 
this is a knowledge of the normal state of the various functions of 
the patient to whom he is called. The modifications made by dis- 
ease in the physiognomy, gait, voice, mental disposition, circula- 
tion and respiration, are often hardly appreciable by the physician 
who has not seen the patient when in health, while they would 
be very manifest to him who can make this comparison. On this 
account we must approve the wise forethought of those persons 
who wish to be known during health by the physician who is to 
attend them when ill. In order to respond properly to the confi- 
dence of these individuals, the physician should thoroughly ex- 
amine the condition of all the functions as he would do in one 
laboring under disease. 

Not only is it necessary for the physician to have exercised his 
senses for the detection of every modification of morbid phenome- 
na, and his mind in determining their value, but he should also 
have acquired by practice, and as far as possible by instruction 
from others, the habit of employing the different modes of explo- 
ration, by the aid of which he attains a knowledge of certain 
phenomena, likely to escape ordinary observation, or at any rate, 
to be far less accurately appreciated. These modes of exploration 
are pressure, palpation, touch, succussion, mensuration, percus- 
sion, auscultation, examination with various kinds of sounds, spec- 
ula, magnifying glasses, the microscope, and chemical reagents. 

1. Pressure. Pressure made with the hands or fingers, and 
which should not be confounded with palpation, is doubtless a 
very simple mode of exploration, but one that furnishes, notwith- 
standing, numerous and important signs. In the first place, it 
enables us to recognise the various changes in the resistance of 
diseased parts, as the hardness of the cellular tissue in phlegmon- 
ous inflammation, the tension of the abdomen in tympanitis, its 
simple resistance in chronic peritonitis, the elasticity of tumors 



DIAGNOSIS. 277 

containing pus, the flaccidity of parts whose volume has rapidly- 
diminished, as the abdomen after the employment of the trocar, 
or after parturition, or that of an inflammatory tumor after the 
natural or artificial evacuation of its purulent contents. 

When, by equable and simultaneous pressure made on both 
sides of the abdomen, with both hands, and over exactly corres- 
ponding regions, a decided and constant difference is perceived in 
regard to the extent to which each hand penetrates, we should 
suspect some deep-seated lesion of the least depressible side of the 
abdomen, even when the hand does not distinguish any alteration 
in the consistence of the tissues. It should not be forgotten that 
an abnormal direction of the dorsal or lumbar portion of the spinal 
column might cause the same sensation, without furnishing the 
same inference. 

When air or serum is infiltrated into the subcutaneous cellular 
tissue, pressure, by displacing the infiltrated fluid, causes, first, a 
sensation of crepitation ; secondly, it conveys the impression of 
penetration by the finger into the compressed part ; and if two 
fingers be used to pinch up a fold of the skin, upon the thigh, for 
instance, they approach each other, and a transient pitting of the 
infiltrated part succeeds this action of the fingers. In typhoid 
fever, when pressure is made in the right iliac fossa, a remarkable 
gurgling is produced, which occurs also, from similar pressure, in 
abscesses into which air has penetrated. 

When a liquid is contained in a cavity which has no outlet, and 
whose parietes are elastic, as the knee or abdomen, rapid pressure 
furnishes us with important signs ; the shock of the patella against 
the opposite surfaces of the femur and tibia, shows a synovial 
effusion which recedes before the finger. When the abdomen is 
simultaneously the seat of moderate effusion, without evident 
fluctuation, and of a tumor so deeply seated as to be inaccessible 
to common palpation, we find a valuable mode of exploration, as 
yet very little known by physicians, in rapid pressure practised 
with the extremities of the fingers. By means of this, we discover, 
often at considerable depth, something resistant against which the 
abdominal parietes strike ; and the sensation of a body which re- 
treats before the fingers and returns immediately on the cessation of 
pressure, indicates that there is liquid interposed between the 
tumor and the integuments, the sound on percussion of the abdo- 
men, as is noticed in these cases, being entirely flat. 

Pressure, also, furnishes certain signs relative to the change it 
effects in the coloration of the parts. 

Certain kinds of erythema, are characterized by the disappear- 
ance of their redness under the pressure of the finger, as erysipelas, 
scarlatina, and roseola ; others by its persistence, notwithstanding 
pressure, or even by its increase, as purptira hccmorrhagica ; the 
reason of this doubtless is, that the surrounding skin becomes 
whiter by pressure, and makes the darkness of the hemorrhagic 
spot more intense by contrast. 

In cases of very slight rubefaction, as that which is diffused 
24 



278 , DIAGNOSIS. 

over the entire surface of the body in sanguineous plethora, or 
around certain joints affected with rheumatism, pressure, made 
with a single finger, causes a discoloration of the compressed point, 
and renders the slight redness of the neighboring parts more man- 
ifest. 

Finally, certain pains, particularly those of an inflammatory 
nature, are aggravated by pressure ; others are not influenced by 
it, as is observed in some cases of sciatic neuralgia ; the intensity 
of others is diminished, as the abdominal pain of lead colic ; others, 
still, are momentarily suspended by strong pressure upon the af- 
fected point, as certain varieties of hemicrania. Lastly, entire ab- 
sence of sensation under pressure sufficiently strong to give pain, 
as that made with the extremities of the fingers, or even with the 
nails, shows complete loss of sensibility. 

2. Palpation. Palpation, or the act of feeling, is one of the 
most useful and most frequently employed means of exploration. 
It consists in the methodical application of the physician's hand to 
the affected parts, for the purpose of appreciating the various alter- 
ations which may have taken place. It requires much circum- 
spection, dexterity and practice united, in order to derive from it 
all the advantage it possesses, to avoid the dangers which it some- 
times occasions and the errors to which it may give rise. The 
following is the best mode of procedure. 

The parts upon which palpation is to be practised, should be so 
placed as that their enveloping muscles may be, as nearly as pos- 
sible, in a state of complete relaxation ; muscular contraction 
would have the double disadvantage of withdrawing the parts 
from the hand of the examiner, and sometimes even of simulating 
tumors, as is particularly the case in regions occupied by inter- 
secting muscles, as the recti abdominis. It is often useful to vary 
the attitude of the patients ; by a comparison of the results ob- 
tained in different positions, we complete, and sometimes rectify, 
the ideas suggested by the first examination. 

It is generally preferable that the parts to be examined should 
be uncovered : delicate linen, however, does not interfere with 
palpation, indeed, it often facilitates it, especially in sensitive per- 
sons, in whom the coldness of the hand employed in palpation, or 
the disagreeable sensations caused by exposure of the person, 
excite involuntary muscular contraction, which ceases with the 
removal of its exciting cause. 

In practising palpation, the whole hand, or even both hands, 
should be used, according to the extent of the parts, and not one 
or more fingers only, except in cases where the volume of the 
affected part will admit of no other mode of exploration. Usually, 
the whole hand should be at once applied to the diseased part, 
instead of pressing perpendicularly, or even obliquely, with the 
extremities of the fingers, as is often done by inexperienced per- 
sons. We should commence by palpation of the neighboring 
parts, or of those similar in kind to the one we wish to examine, 
as for example, the healthy limb, breast, testicle, or side of the 



DIAGNOSIS. 279 

abdomen, previously to those affected, so that we may, by a 
knowledge of the normal condition, better appreciate the altera- 
tions, sometimes slight, produced by disease in the unhealthy 
parts. The hand should at first be simply applied to these 
parts ; if it encounter no resistance and produce no pain, we 
should gradually exert more pressure, directly, at first, afterwards, 
with slight lateral movements. When we discover an enlarge- 
ment or swelling, we should endeavor to circumscribe it completely, 
by surrounding it on all sides with the fingers, sufficiently flexed 
and separated from each other, to be applied to the whole of the 
resisting or swollen surface, and thus ascertain its limits. Fre- 
quently, one of the hands should be so placed as to favor the exam- 
ination which is particularly conducted by the other : thus, in order 
to verify an obscure fluctuation, we press back the fluid with one 
hand towards the place where the other hand is applied : in exam- 
inations of the abdomen, one hand, applied to the right lumbar 
region, pushes the liver forward, so that the other hand can better 
appreciate its volume and its consistence. Tn order that the hand 
placed upon the hypogastrium may ascertain the condition of the 
uterus, it is often requisite to raise the os tincse with the index 
finger of the other hand. In the examination of inflammatory 
tumors, abscess, certain species of hypertrophy, various kinds of 
organic degeneration, and arterial aneurism, palpation furnishes 
signs of peculiar value, especially when uniformly identical results 
are obtained on repeated trials at different intervals. It enables 
us to discover the number, size, form and consistence of the above 
tumors, to judge whether their surface be smooth or uneven, 
whether they are soft or hard, and if these qualities characterize 
them throughout or only partially ; whether they are elastic or 
fluctuating, unique or multiple, fixed or movable ; if they exhibit 
internal movements or pulsations ; if these pulsations be isochro- 
nous, or not, with those of the heart or arteries, if they are the 
effect of simple displacement, or of an actual expansion, if they 
may be referred to that undulatory thrill observed in many dis- 
eases of the circulatory system, especially in certain alterations of 
the cardiac orifices and in varicose aneurism, etc. 

Palpation, moreover, repeated at suitable intervals, enables the 
physician to judge of certain changes which time and remedies 
effect in the course of diseases ; diminished or increased volume of 
parts already examined becomes in this way the most certain of 
signs, and is suggestive of the most positive ideas. We should, 
however, remember that various modifications, taking place either 
in the situation of the tumor or in the surrounding parts, may 
sometimes deceive the practitioner. A cancerous tumor, developed 
in the greater curvature of the stomach, is more or less apparent 
according to the state of vacuity or repletion of that viscus, and 
in proportion to the amount of gas contained in the neighboring 
intestines. We have so frequently observed, in cases of this de- 
scription, and in others analogous, the difficulty of reaching the 
tumor lead to the supposition of its decrease, or even its disap- 



280 



DIAGNOSIS. 



pearance, that we have thought proper particularly to notice this 
source of error. 

The simple changes wrought hy disease in the natural solidity 
of the organs, are, moreover, important phenomena to establish, 
and can only be appreciated by means of palpation. Not to men- 
tion that relaxation of the integuments and muscles, which is, as 
it were, the first stage of emaciation, and which in some instances 
furnishes us with an important sign, we would notice that cir- 
cumscribed hardness and the consecutive engorgement of a certain 
portion of the integuments, where deep-seated inflammation is 
developed, or purulent matter collected; finally, we would call to 
mind that resistant state of the abdomen so precious in the diag- 
nosis of certain cases of chronic peritonitis. 

3. Examination by the Touch. Touch* is a species of palpation 
made by one or more of the fingers, introduced into parts naturally 
inaccessible to the eye, as the vagina and rectum, with the design 
of verifying different physiological and morbid conditions, either 
of these passages, or of neighboring organs. 

The index finger of either hand is usually the only one employed 
in vaginal and rectal examinations ; it is very rare that diagnosis 
is assisted by the introduction of two fingers into the same pas- 
sage ; but in some circumstances, when we wish to examine the 
recto-vaginal parietes, we introduce, simultaneously, the thumb 
into the vagina, and the index finger of the same hand into the rec- 
tum. The nail of the finger which is used in such examinations 
should be short, and smooth, so that the pulp of the finger may be 
more accurately applied to the parts, and no pain or laceration be 
produced. Previously to such an examination, the bladder, and 
especially the rectum, should be evacuated. These preliminaries 
being fulfilled, and the finger being covered with cerate or some 
other unctuous or mucilaginous substance, we proceed as follows, 
for vaginal and rectal examinations. 

If we intend to examine the vagina and uterus, the woman may 
be either recumbent or erect. If the former position be adopted, 
she should assume the dorsal decubitus, the body being somewhat 
inclined upon the pelvis, so as to relax the muscles as completely 
as possible, the thighs being slightly separated and flexed. The 
physician should stand, by preference, at the right side of the bed, 
so that he may use the index finger of the right hand. If the pa- 
tient be in the upright posture, she should be requested to lean 
upon some firm support, separating the thighs slightly, and the ex- 
aminer should be before her, upon a low seat, or resting upon one 
knee. Whatever be the position, we should avoid exposure of the 
patient under an examination more or less trying to nearly all 
females. With the thumb and middle finger of the hand em- 

* The term "toucher," which we have rendered by the English word touch, 
is used in a medical sense, by the French, to express explorative examination by 
the finger, usually, the index finger of the right hand ; in some rare cases, two 
fingers are used, as is mentioned in the text. The term is employed, in the vast 
majority of cases, to indicate vaginal exploration with the finger. — Trans. 



DIAGNOSIS. 281 

ployed, we slightly separate the labia majora of the vulva, the 
index finger is readily introduced into the vagina, while the other 
fingers are strongly flexed upon the palm of the hand. The finger 
should enter the vagina slowly, in order to avoid the pain which 
might be occasioned by a rapid introduction, and to appreciate 
more thoroughly either the changes which may be detected in the 
parietes of the passage, as regards heat, sensibility, consistence, 
form, and moisture, or, in certain cases, to ascertain the formation 
of the pelvic cavity. When the finger has reached the os tincae, 
which will be recognized by its form, consistence, and by the 
central depression which distinguishes its orifice, we ascertain 
if it be in its normal position, if depressed or inclined to the 
right or left, forward, or backward ; the sensibility, length and 
volume of the neck, whether it be hard, or soft, sometimes the in- 
equalities of its surface, the relative size of the two labia oris 
tineas, the degree of dilatation of its orifice, as well as its form, ele- 
vation and direction, should each be the objects of attentive exam- 
ination. We next proceed to the examination of the uterus. For 
this purpose, raising the finger, as if to elevate the organ, and 
carry it backwards, towards the brim of the pelvis, we judge of its 
weight and mobility, and if the woman be pregnant, we may thus 
determine and perceive the repercussion {ballottement) of the foetus. 
When the patient is in a horizontal position, the unoccupied hand 
should be placed upon the hypogastrium, in order to appreciate the 
volume of the uterus, and accurately determine its elevation ; by 
this means, we may, in certain cases of abdominal tumors of diffi- 
cult diagnosis, gain a more accurate knowledge of their seat and 
connections ; by alternate pressure of the hand, applied to the ab- 
domen, and of the finger resting upon the uterus, we can generally 
ascertain whether the tumor under examination be formed by the 
uterus itself, merely attached to it, or distinct from it. 

In order to derive all the advantage possible from this mode of 
exploration, it is often necessary to change the position of the pa- 
tients, and to place them alternately in the horizontal and upright 
position. The latter is particularly useful when we wish to ascer- 
tain with accuracy certain deviations of the uterus, especially pro- 
lapsus, or to verify the phenomenon of repercussion of the foetus. 
In all cases where morbid changes in the vagina, or the neck of 
the uterus, are discovered by the touch, the physician should ex- 
amine ocularly, and by the sense of smell, the finger which has 
been employed, in order to judge of the changes which may have 
occurred in the vaginal mucus, or any other matters remaining 
upon the finger. 

In rectal examinations, the horizontal posture will generally be 
convenient, the body being inclined to one side, with the corres- 
ponding limb extended, the other slightly flexed. The index finger 
should be introduced more slowly than in vaginal examinations ; 
and in case of strong contraction of the sphincter, we should wait 
for its relaxation. Still greater caution is requisite when the margin 
of the anus is the seat of hsemorrhoidal tumors, or of fissure. The 
24* 



282 DIAGNOSIS. 

finger thus introduced into the intestine should be moved gradually 
over the whole internal surface, in order to appreciate the various 
modifications which may exist, in its sensibility, tension, heat and 
consistence, or, as regards any inequalities it may present, such as 
granulations, wrinkles, ulcerations, tumors, with, or without a pedi- 
cle, fraena, strictures, or dilatation of this portion of the rectum. 
The rectal touch may moreover discover, in the male, through the 
recto-vesical parietes, calculi, engaged in the inferior extremities of 
the ureters, or occupying the base of the bladder, or tumefaction 
and induration of the prostate, which is a frequent cause of reten- 
tion of urine. In the female, we may by this means detect aug- 
mented volume of the uterus, its deviation from the normal posi- 
tion in retroversion, and certain fibrous tumors developed in its 
posterior parietes, near its external surface ; it also furnishes valu- 
able signs in certain forms of extra-uterine pregnancy, and, in 
some very rare cases, reveals the absence of the uterus. 

Vaginal or rectal touch is also indispensable for the diagnosis of 
diseases which have their seat in the pelvic cavity, exteriorly to 
these passages and the organs with which they are immediately 
connected ; such as that kind of abscess which often occurs 
after parturition, and scirrhous tumors and exostoses developed 
within the pelvis, which would remain unknown in most cases, if 
this mode of exploration did not enable the physician to seek for 
and discover them. 

The thorough exploration of the posterior fauces, by means of 
the finger, may be considered analogous to the above, its purpose 
being to examine the most remote portion of the nasal fossa? above, 
and the various alterations of the epiglottis, arytenoid folds, and 
middle portion of the pharynx, below. This examination, in 
which we are sometimes obliged to keep the maxillae separated 
by means of some resistant body placed between the molar teeth, 
may suffice of itself, in some cases, to establish the diagnosis of 
certain very obscure diseases, as polypi developed in the nasal fos- 
sae, oedema of the glottis, abscess and foreign bodies in the pharynx. 

In concluding our remarks upon this mode of exploration, we 
deem it necesary to repeat an opinion daily expressed in our clini- 
cal lectures, viz., that this kind of examination is too much neg- 
lected, that most physicians are not aware how much information 
it supplies, nor how many errors may be avoided or rectified by its 
aid ; and that consequently, it is an imperative duty to have re- 
course to it whenever any circumstance draws our attention to 
those organs where its application is possible. 

4. Succiission. Succussion consists in shaking the patient's 
body with sufficient force to agitate the fluids and gases contained 
in one and the same cavity, and to cause more or less distinct 
gurgling. 

A lateral shock given to the body, and frequently repeated, by 
means of the two hands placed upon the lower part of the chest, 
one on the right, the other on the left side, usually enables us to 
detect this species of gurgling, without the necessity of ausculta- 



DIAGNOSIS. 283 

tion ; in most patients the sound is sufficiently distinct to be per- 
ceived at a considerable distance. 

Succussion is applicable to but a small number of diseases. We 
cannot, indeed, produce the sound above-mentioned, except in cases 
where gas and liquids are contained in the same natural or acci- 
dental cavity, and such affections are rare ; the principal are hy- 
dro-pneumothorax, (an affection almost always consecutive upon 
the ulceration of pulmonary tubercles, with perforation of the 
pleura,) and certain affections of the stomach, among which the 
dilatation consequent on scirrhus of the pylorus is the most fre- 
quent. In the latter case, the gurgling is produced in the abdo- 
men ; in the former it takes place in the thorax. A fold of intes- 
tine, considerably dilated, may also present this phenomenon, if 
succussion be practised. We detected it upon one occasion, in a 
cyst of the ovary, which contained, as was discovered at the post- 
mortem dissection, pus of creamy appearance and very fetid gases, 
which, as it seemed to us, were probably produced by the putrefac- 
tion of this liquid. We should add that there are certain persons, 
whose digestion seems regular, in whom stomachal gurgling occurs 
on succussion, after the ingestion of liquid aliment. 

5. Mensuration. Mensuration, as the word imports, is that 
mode of examination, by which we endeavor to determine with 
more accuracy than is attainable by either sight or touch, the 
volume or length of certain diseased, or healthy parts. For this 
purpose we employ, according to the form of the parts, either an 
inelastic band, or a pair of callipers {compos d? epaisseur), with a 
scale divided into centimetres or lines ; in many cases, the physi- 
cian will find his fingers the most natural and available instrument 
for mensuration. 

Certain precautions are necessary in the application of this 
method of exploration, so as to give to its results the accuracy 
which constitutes their utility. The first is a uniform degree of 
pressure in all the successive measurements ; the second, a like 
uniformity and precision in regard to the posture of the patient, 
and particularly the position of the parts to be examined : the 
position should, if possible, be rectilinear, so that future examina- 
tions, made in exactly the same manner, may accurately exhibit 
the alterations, if any have supervened. If mensuration be ap- 
plied to the head or the thorax, the patient should be either sitting 
or erect ; his posture should be the horizontal, when the limbs and 
abdomen are to be measured. Another point of equal importance 
is to apply the instruments upon exactly the same points ; the 
nipple and the umbilicus, in mensuration of the abdomen and 
thorax, may serve as limits {jalons). 

Mensuration may be very advantageously applied in diseases 
which change the direction or the relations of one or more portions 
of the osseous system. It proves the existence of disorders which 
the eye would only lead us to suspect, and enables us to determine 
their extent and to trace their changes ; on this account it is fre- 
quently employed by orthopedic surgeons. We cannot, however, 



284 DIAGNOSIS. 

too often repeat how important it is in these cases, as well as in 
moulding in plaster, to maintain strict uniformity of attitude, in 
order that each ulterior examination may be conducted under pre- 
cisely similar conditions. 

In estimating the length of the lower limbs, mensuration pre- 
sents some difficulties with which we should be familiar; lateral 
inclination of the pelvis might erroneously lead us to suppose elon- 
gation or shortening of a limb, did we not possess, in the ingenious 
process proposed by Professor Sanson, a sure means of ascertaining 
the direction of the pelvis, * and consequently of rectifying the 
error. 

More difficulty is encountered in mensuration of the chest, than 
in that of any other portion of the body, on account of its alter- 
nate movements of dilatation and contraction and its frequent 
faulty conformation. The object of thoracic mensuration is, to 
determine whether there exist enlargement or diminution in the 
volume of either side. The following is the mode of procedure. 

The patient should be seated, the arms separated from the body, 
and the hands clasped upon the head. The spinal processes of 
the dorsal vertebrae distinguish the median line posteriorly ; a cord 
drawn from the superior extremity of the sternum to the ensiform 
cartilage marks it anteriorly. A graduated riband passed from 
one of these points to the other, across each side of the thorax, to 
the level of the nipple in the male, and just beneath the mamma in 
the female, enables us to ascertain accurately the comparative size 
of the two sides of the chest, in the alternate movements of in- 
spiration and expiration. In aid of this process, which should be 
repeated at suitable intervals, the physician should follow out the 
changes induced by certain diseases in the volume of the chest, 
particularly by pleurisy with effusion. 

This kind of mensuration, however, is not always sufficient for 
the appreciation of alterations in the volume, and, particularly, the 
capacity of the thorax. In some cases, indeed, where circular 
mensuration detects no difference in the extent of surface, simple 
inspection will show considerable antero-posterior depression of one 
side, and by means of the graduated callipers, and particularly 
the instrument which we have constructed for this purpose, f a 
difference of from an inch to fifteen lines in the antero-posterior 
diameter of the two sides may be detected, and, what is of more 

*This process consists in letting fall, from the upper part of the body to the 
pubis, a vertical line represented by a cord reaching from the superior notch of the 
sternum, to the symphysis pubis, and crossing another cord extending from one 
anterior superior spinous process of the ilium to the other. Before measuring 
the limbs, we should so place the pelvis, as that the cords shall cross at right 
angles. 

J This instrument, which is very similar to that used by shoemakers for meas- 
uring the foot, differs from it in having upon each of its branches, a movable 
plate ten or twelve lines in breadth, which, resting with a broad surface upon the 
chest, cannot, like the branch of the instrument, be alternately placed upon an 
intercostal space and a prominent rib, which condition would alter the results of 
mensuration and might lead to erroneous conclusions. 



DIAGNOSIS. 285 

importance, it reveals a far greater change in the capacity of the 
thorax, than that occurring in cases where the extent of surface, 
only, is diminished. These two modes of exploration have ena- 
bled us to ascertain two facts, of considerable interest in the his- 
tory of pleuritic effusions : first, that the chest, although much 
contracted after chronic pleurisy, may regain, in the course of 
years, its original dimensions ; secondly, that in those cases where 
one side becomes contracted by reason of the compression and 
atrophy of the lung therein contained, the other side is enlarged, 
as if to supply the loss of power in its companion, in conformity 
with the known laws of pathological physiology. We shall men- 
tion a single fact, only, in support of each of these observations. 

Dr. D., member of the Faculty of Paris, in the course of a 
chronic pleurisy of the left side, had dilatation of the side and 
subsequent contraction, as is observed in the majority of patients ; 
by means of often repeated circular and antero-posterior mensura- 
tion, the various modifications of the conformation of the thorax 
were followed and appreciated. After several years, it was desir- 
able to examine anew, in order to judge of the changes gradually 
wrought by time in the respiratory murmur, which had remained 
feeble, and also in the conformation of the left side, which, after 
seven or eight months of disease, was still much contracted. This 
last examination, made three or four years after the apparent cure of 
the disease, convinced us that the respiratory murmur had regained 
its normal type, and what was yet more surprising, that the left 
side had not only re-attained a size equal to that of the right, but 
that it had become larger, both in regard to its superficies, circu- 
larly measured by a riband, and in its antero-posterior diameter, 
measured by the instrument above mentioned. It is possible that 
this side may have been originally larger than the right. 

The second fact relates to a phthisical young girl, who was 
brought to the clinical wards of La Charite with all the signs of 
pneumo-thorax upon the left side, and in whom suffocation seemed 
imminent. Liquid effusion succeeded to that of gaseous nature, 
and its absorption was very gradual ; mensuration, at intervals of 
eight or ten days, established that the right side was progressively 
dilated, in proportion to the contraction of the left, although the 
contraction of the latter must have opposed the enlargement of the 
former. This patient survived the attack of pneumo-thorax, and 
died two years after, from the gradual progress of phthisis. 

Mensuration of the abdomen is performed with a graduated 
riband, or with a plain one, upon which the result of each meas- 
urement is marked with ink. This exploration is particularly 
useful in abdominal dropsy, where it enables us to appreciate even 
the slightest modifications in the volume of the abdomen, and to 
deduce from thence our inferences as to the effect of the treatment 
employed. It is important, however, to remember that the volume 
of the abdomen depends both upon the quantity of liquid con- 
tained in the peritoneum or in a cyst, and upon that of gases and 
other matters confined in the intestines. The alterations which 



286 DIAGNOSIS. 

supervene in the volume of the abdomen, do not, then, give us the 
exact measure of the existing modifications in the quantity of 
liquid contained in the abdomen : percussion must concur with 
mensuration in forming the opinion of the physician in such cases. 

Mensuration is still farther applicable to certain tumors, which 
are sufficiently superficial to allow of being included between the 
branches of the callipers ; although little employed, there are cer- 
tain cases where it may be useful ; a greater degree of precision in 
the appreciation of the changes which supervene in the volume of 
these tumors, furnishes prognostic and therapeutical indications 
which should not be neglected. 

Finally, mensuration becomes a valuable means in the appreci- 
ation of the pelvic diameters, especially the antero-posterior, whose 
extent it is very important accurately to ascertain, with reference 
to parturition, particularly in deformed females. Several instru- 
ments invented for this purpose and called pelvimeters,* have 
been abandoned; the index finger is to be preferred, introduced to 
a sufficient depth into the vagina, to reach with its extremity the 
sacro-vertebral angle, while its base rests beneath the symphysis 
pubis ; we can thus estimate this diameter within one or two lines. 

6. Percussion. Percussion is that mode of exploration whose 
special purpose is to ascertain the degree of resonance presented 
by various parts of the body. It is by a species of percussion, 
likewise, that we obtain that internal impulse, caused by a sudden 
shock communicated to a liquid confined in a natural or accidental 
cavity (fluctuation) , or to a mass of hydatids enclosed in a cyst 
(Jiydatic fremitus) ; but it is the first kind of percussion only, 
which will be here considered. 

From the earliest times of medicine, percussion seems to have 
been employed in examinations of the abdomen : the term tympa- 
nitis, applied by the Greek physicians to considerable gaseous 
distension of the abdomen, puts it beyond a doubt that they had 
noticed, by means of percussion, the increase of resonance in this 
region. The utility of percussion, however, was then but limited : 
it barely sufficed to distinguish between dropsy and tympanitis. 
For this reason, Avenbrugger has very generally and justly been 
considered the inventor of this mode of exploration, which he was 
the first to apply to the study of thoracic diseases. Since the pub- 
lication of his work, in 1763, and especially since its translation 
into French by the celebrated Corvisart (i8(J8), percussion has 
become one of the most employed and most useful of diagnostic 
means: every day has added to its importance, either because it 

* A new and very simple pelvimeter has been contrived, consisting of two pieces 
of wood, each one eighth of an inch square and eight inches long, fastened 
together in the centre by a pivot, so as to form a cross with equal legs. The 
lower extremity of one of these legs has a graduated transverse bar attached, 
upon which the other leg traverses. Thus, whatever space is ascertained by the 
expansion of the upper legs of this double compress, is marked by the separation 
of the lower. All that is required, therefore, is to introduce the upper end, 
closed with the finger, and to open it when in the pelvic cavity. — {Medical 
Gazette, Oct. 30, 1846). — Trans. 



DIAGNOSIS. 287 

has been more carefully studied and more extensively applied, 
or because the discovery of auscultation has given more precision 
to the value of the signs furnished by percussion. Finally, by the 
recent labors of many physicians, and particularly of M. Piorry, 
percussion, applied to the observation of abdominal disease, has 
furnished a new series of very useful diagnostic signs. (See 
page 151). 

In order thoroughly to appreciate the changes wrought by dis- 
ease in the resonance of the thorax, the physician should be aware 
that there is great variation in regard to the degree of resonance 
in different individuals, and that, in the same individual, percus- 
sion furnishes different results, according to the parts of the chest 
upon which it is practised. Broad chests, clothed with voluminous 
muscles, give, most generally, an obscure sound on percussion, 
whatever portion may be examined. In very thin persons, on 
the contrary, the chest resounds clearly, and is almost tympanitic 
throughout. In all cases the resonance of the thorax varies ac- 
cording to the regions : it is more clear beneath the clavicles, in 
the axillary regions and in the lateral portions; less so over the 
scapulae and in the prsecordial region ; the latter returns an obscure 
sound, over a surface of from one and a half to two square inches, 
which indicates the space where the heart remains uncovered by 
the lungs ; but in some persons, the heart, deeply situated in the 
mediastinum, has its anterior surface entirely covered by the lung, 
and percussion, practised upon the cartilages of the fifth and sixth 
ribs and the lower part of the sternum, gives an entirely clear 
sound. Below the heart, the thoracic resonance usually becomes 
clearer than anywhere else, which is owing to the presence of the 
stomach and its gaseous contents ; on the right side, in a corres- 
ponding point, the sound is dull, which is referable to the liver. 
It has been said that the resonance of the right side was of deeper 
tone by reasen of the greater volume of the lung ; but we do not 
consider this difference sufficiently established. 

Percussion has long been practised, directly, with the palm of 
the hand, or with the extremities of the fingers. This mode of 
percussion has the disadvantage of causing some pain, particularly 
in the mammary and abdominal regions, and it has become the 
practice to interpose some substance between the hand used in 
percussion and the part percussed, thus diminishing the pain, 
while the degree of resonance is the same or even increased. The 
latter kind of percussion is called mediate, the former immediate. 
Many instruments have been devised for mediate percussion. An 
ivory plate with projections, so that it may be firmly held (plexi- 
meter), a piece of silver, or of caoutchouc, have all been proposed; 
but Ave prefer the index finger of the hand not used in percussion, 
(and this is usually the left,) because it can be better applied to the 
chest, and causes less noise than either ivory or metal, and also, 
because, as a general rule, the physician should not have recourse 
to instrumental aid, except in cases where the hand is insufficient. 
It has been suggested that the finger which serves as an interme- 



288 DIAGNOSIS. 

diate body, be placed in supination, in order to percuss upon the 
softer palmar portion, which is less sonorous than the dorsal por- 
tion : we regard this modification as of little consequence, and 
employ the finger either in supination or pronation, according to 
the patient's position, without remarking any appreciable differ- 
ence in the results obtained. 

Whatever mode of percussion be preferred, certain rules should 
be observed in its practice. 

It is a precept of general application in all modes of exploration, 
to commence by an examination of parts somewhat remote from 
the supposed seat of disease ; this rule is equally applicable to 
pressure, palpation, percussion and auscultation : a previous exam- 
ination of healthy parts admits of more accurate appreciation of 
the alterations, sometimes but slight, which take place in diseased 
parts. There are, however, some exceptions, and if the patient 
submitted to percussion or auscultation of the chest, be so feeble that 
he can with difficulty assume a sitting posture, even for a few 
seconds, it is preferable to examine the affected side first, lest syn- 
cope might prevent a more extended examination. 

When either percussion or auscultation are practised, the patient 
should be in a quiet room, and those present should remain mo- 
tionless and silent. 

The parts subjected to percussion should be bare, or only very 
thinly clothed. The patient should be in a sitting posture during 
percussion of the thorax ; the dorsal decubitus is suitable in percus- 
sion of the abdomen, and is admissible, also, for the front chest. 
The arms should be maintained in similar positions, hanging by 
the sides of the body, when we percuss in front or behind ; raised, and 
the hands clasped upon the head, when the lateral regions are per- 
cussed. The physician may stand indifferently on the right or left 
of the patient for percussion of the abdomen ; for that of the thorax, 
his position should be such as will enable the fingers of the most 
practised hand, which is usually the right, to strike at right angles 
and with uniform force upon corresponding points of the chest, on 
each side, either anteriorly or posteriorly ; this is one reason for 
desiring persons who are not ill enough to be confined to bed, to 
sit on a chair when examined. If the results are at all doubt- 
ful, we should percuss comparatively, standing alternately at the 
right and left of the patient, and employing both mediate and im- 
mediate percussion. 

It is generally best, in children and thin persons, to employ medi- 
ate percussion, with a single finger : the medius is preferable, which, 
by its greater length, naturally extends beyond the others. If the 
thoracic integuments are of considerable thickness, and especially 
if there be much adipose tissue, a greater degree of force will gen- 
erally be necessary, and two fingers, as the medius and index 
united, should beemployed, and sometimes, even all the fingers joined 
together and forming a line. Percussion should be gentle at first, 
being thus less painful and disagreeable to the patient, and also 
because, in this way, the sound caused by the percussing finger 



DIAGNOSIS. 289 

is nearly null, and the internal resonance more easily appre- 
ciated. The force with which we percuss, may gradually be 
augmented, until we attain that degree which gives the most 
marked results. 

Should nothing indicate existing lesions within the thorax, we 
limit our percussion of its several regions to three or four points; if 
we have any reason to fear concealed lesion, we should percuss 
much more frequently, and not renounce the idea of discovering 
some disorder, until we have examined, not only by percussion, but 
by auscultation, nearly every point of the thoracic surface. 

Abdominal percussion is generally practised by tapping with 
the medias of the right hand upon the index finger of the left, 
which is made to glide successively from above downwards over 
the abdominal parietes, from the ensiform cartilage to the pubis, 
and from the margin of the ribs, on each side, to the ossa ilia. 
The resonance of the abdomen, like that of the chest, varies, in 
health, according to the thickness of the integuments and the flesh 
of the patients, and also according to the amount of gas contained 
in the alimentary canal, which may vary very much without consti- 
tuting a morbid condition. The resonance of each abdominal 
region is generally proportionate to the diameter of the organs 
containing the gaseous fluid : in the normal state, the stomach 
gives the clearest sound on percussion, and the large, are more re- 
sonant than the small, intestines. 

Abdominal percussion, in disease, conjointly with palpation 
and pressure, furnishes a great number of important signs. In 
cases of general distention of the abdomen, it assists us in ascer- 
taining whether the swelling be owing to an accumulation of gas 
in the intestinal canal, to liquid effusion, or to a large, solid tumor 
entirely filling the cavity. In the first case, there is increased, in 
the two others, diminished, resonance : in one of the latter cases, 
fluctuation reveals liquid effusion ; in the other, the absence of 
fluctuation and the greater resistance to pressure declare the exist- 
ence of a solid abdominal tumor. 

In cases where the abdomen presents only a partial tumefaction, 
percussion upon such a point, when a clear sound is returned, indi- 
cates that the swelling is owing to gaseous distention of a portion 
of the intestinal tube ; when the sound is flat, the presence of a 
solid tumor or liquid effusion may be suspected as the cause, and 
in certain cases where there is a medium and variable resonance, 
a fold of intestine may be contained in the tumor, without consti- 
tuting it entirely. Percussion, in conjunction with other modes of 
exploration, assists the diagnosis of peritoneal effusions, of tumors 
formed by the uterus and ovaries in females, by the bladder, 
spleen and liver in both sexes, and reveals the alterations effected 
by time and remedies in the course of these diseases. 

Percussion, while it allows the ear to distinguish important mod- 
ifications in the degree of resonance of diseased parts, imparts, 
also, a peculiar sensation to the finger, which may be valuable in 
certain cases. Thus, according to the observations of M. Piorry, 

25 



290 DIAGNOSIS. 

when a multilocular ovarian cyst exists in the abdomen, whose 
compartments contain various substances, each of them may pre- 
sent a different degree of resistance to the finger, and this phenom- 
enon concurs with pressure and palpation in the determination of 
the seat and nature of the tumor. 

7. Auscultation. — Auscultation is that mode of exploration whose 
purpose is to ascertain, by the mediate or immediate application of 
the ear to different parts of the healthy or diseased body, the 
various sounds which may be produced, and to appreciate their 
semeiological value. 

Auscultation was at first applied by its inventor to the study of 
thoracic affections only, and we have previously seen (pp. 138, 166), 
what a number of important signs it has furnished in the diag- 
nosis of diseases of the lungs, heart, and their respective envelopes. 
But Laennec himself was aware that it might be extended to 
other affections, especially to certain diseases of the middle ear, 
the Eustachian tube and the mastoid cells. Subsequently, a number 
of English physicians declared its utility in certain cases of peri- 
tonitis with formation of false membranes. MM. Mayor of Ge- 
neva, Kergaradec, and afterwards M. Paul Dubois and the younger 
Noegele, have published interesting researches upon the application 
of auscultation to the study of pregnancy, and of certain condi- 
tions of the foetus during intra-uterine life. Finally, some sur- 
geons have declared, that in those deep-seated fractures where 
crepitation was doubtful, and in cases of urinary calculi where 
the shock of the sound against the foreign body communicated 
only an obscure and doubtful sensation, they could, by means of 
auscultation, distinctly hear the collision of the bony fragments and 
the light touch (frolemeni) of the catheter against the surface of 
the calculus. * 

Auscultation may be practised in two ways : either by the in- 
tervention of the acoustic instrument known as the stethoscope 
{mediate auscultation) ; or by the direct application of the unassist- 
ed ear to the parts we would examine (immediate auscultation). 

Mediate auscultation was the only method advised and practised 
by Laennec, who found inconveniences in immediate auscultation 

* The application of auscultation to the diagnosis of cerebral disease, was first 
introduced to the profession in 1834, by Dr. Fisher, of Boston. Subsequent and 
more extended researches led him to announce the existence of an encephalic 
bellows murmur in many cases of apoplexy and fracture of the skull, in addition 
to the diseases wherein it was first declared to be evident, viz., acute and chronic 
meningitis, encephalitis, during the accidents of dentition and in pertussis. The 
conclusions drawn by Dr. Fisher from his researches are the following : 1. The 
encephalic bellows murmur does not exist in the normal state of the encephalon. 
2. It may be easily distinguished from the other sounds heard while ausculting the 
head, as the sound produced by the passage of air through the nares, by degluti- 
tion, locution, and the cardiac pulsations. 3. Its seat is the arterial trunks at the 
base of the skull, when they are compressed by the brain ; as occurs in effusion 
or in inflammatory increase of volume of the organ. The calibre of the arteries 
being diminished, the circulation is impeded, and this, in addition to the resulting 
increase of friction, is the source of the bellows murmur. (See American Jour- 
nal of the Medical Sciences. August, 1838.) — Trans. 



DIAGNOSIS. 291 

which seem to us fictitious.* In the last edition of this work, we 
asserted, that in our own experience, immediate auscultation had 
presented the same exactitude, in its revelations of the various 
auscultatory phenomena, as that by means of the stethoscope, even 
when employed by the most skilful. Fifteen years of observation 
have confirmed this opinion more and more, and it is entirely 
proved, that all the modifications of the respiratory murmur, and 
all the rales and abnormal sounds of which the lungs, heart and 
their enveloping membranes may be the seat, are as appreciable by 
the unassisted ear, as by the aid of the stethoscope. A certain de- 
gree of practice is requisite in both these methods of exploration ; 
but skill is far more easily acquired in immediate than mediate 
auscultation. One who accustoms himself to the stethoscope, hears 
with more difficulty when he uses the unaided ear ; another, (and 
this is our experience) more familiar with immediate auscultation, 
appreciates far better, by its means, the phenomena arising from 
the respiration, voice, and movements of the heart. But, supposing 
these two methods to be the same, should we not prefer the most 
simple ? 

Immediate auscultation presents still other advantages : 1. It 
requires less time, which, indeed, is of little importance in ordinary 
cases, but is not to be disregarded in those where the debility of 
the patient barely allows him to retain, even for a few minutes, the 
sitting posture, a circumstance of frequent occurrence. 2. The atten- 
tion of the physician is not divided between maintaining the stetho- 
scope in exact application to the parts he is examining, and the 
appreciation of the phenomena which he studies ; it is not impossi- 
ble, especially in the case of those who have not acquired great skill 
in the use of the stethoscope, that this instrument, being improperly 
applied, may lead the observer into error in regard to the phenom- 
ena which he is desirous of studying, while immediate ausculta- 
tion would present no such difficulties. 

* Immediate auscultation is equally inconvenient for the physician and the pa- 
tient ; disgust, alone, renders it impracticable in hospitals ; it is hardly to be 
thought of with the majority of females, and in some, the size of the mammae is 
a physical obstacle to its employment ; these are Laennec's objections 

To this we reply: 1. Immediate auscultation is less inconvenient for the phy- 
sician than mediate, by reason of the firm support which ihe patient's chest affords 
the head ; it is less painful for the patient, for the pressure of the ear is softer 
than that of a wooden instrument; 2. Disgust does not render any mode of ex- 
ploration impracticable; it is also completely conquered by habit. 3. Immediate 
auscultation may be practised with such propriety that no reasonable female would 
object to it. 4. Considerable volume of the mamma? is quite as great a hindrance 
to the employment of the cylinder, as to that of the ear. 5. Lastly, to a final 
objection offered by Laennec, viz. " that all the parts of the observer's head, 
which touch the thorax, becoming so many conductors of sound, might cause the 
respiratory murmur to be heard in cases where it did not exist in the part situated 
directly beneath the ear, which might occasion serious error," we reply, that in 
no case have we seen this supposition realized, and that the most circumscribed 
lesions of the lungs have seemed to us as easily distinguished by ihe unaided ear, 
as by means of the stethoscope. In conclusion, we add, as confirmatory of our 
opinion, that, at present, the great majority of practitioners only use the stetho- 
scope in those cases where there exists an obstacle to immediate auscultation. 
(See p. 292 ) 



292 DIAGNOSIS. 

There are, however, some cases where mediate auscultation is 
preferable. In the examination of an cedematous chest, the pres- 
sure of the stethoscope displaces the serosity and enables us better 
to appreciate the phenomena of auscultation. At other times, the 
form of the parts prevents the accurate application of the ear, and 
renders immediate auscultation impracticable. In some phthisical 
patients, for instance, where the emaciation is excessive, the con- 
siderable prominence of the clavicle and acromion process of the 
scapula does not admit the application of the ear to the thoracic 
parietes in the hollow circumscribed by these bones. The same is 
true in certain cases of rachitis, where, by reason of deformity of 
the thorax, the stethoscope alone can be employed ; such is also 
the case, and for analogous reasons, in auscultation of the arteries ; 
for if we except the celiac axis and the arch of the aorta, to 
which the ear can, if necessary, be directly applied, we must use 
the stethoscope for all the others, either with or without its sup- 
plementary portion, or plug {enbont). Too strong pressure upon 
the artery with this instrument should be avoided ; its effect would 
be to produce a bellows murmur in the vessel, which would 
simulate a morbid sound. 

Mediate or immediate auscultation is practised as follows : 

In the first place it is more convenient entirely to uncover the 
part about to be examined ; the interposition of linen alone is not, 
usually, any obstacle to this sort of exploration ; indeed, we some- 
times observe that certain thick articles of clothing, and those 
doubled, do not always prevent the perception of auscultatory 
phenomena. We have often appreciated these phenomena with 
great accuracy through the thick garments worn in the cold season, 
and also, through linseed cataplasms entirely enveloping the tho- 
rax in children. On other occasions, the contrary is observed, 
and very thin clothing, as the corsets in females, or the starched 
shirt-bosom in males, almost wholly prevents the perception of 
phenomena afforded by auscultation. As a general rule, when 
nothing opposes, it is better to auscult the bare surface. 

It is equally necessary, in order to the exact perception of aus- 
cultatory phenomena, that the muscles, interposed between the part 
examined and the ear of the observer, be entirely relaxed ; their 
contraction might have the double disadvantage of altering the 
transmission of the sounds we wish to study, and of mingling with 
them other sounds arising from the muscular contraction itself. 

In mediate auscultation, the stethoscope should be held like a 
pen, the hand being placed very near the part to be examined, in 
order to be sure that the instrument is accurately applied. If the 
patient be in bed, he should lie upon the back or assume a sitting 
posture, and the anterior parts of the chest should be examined in 
this position, the auscultator standing alternately upon each side 
of the bed ; in the examination of the lateral portions and axillary 
regions, the patient should be inclined to the opposite side ; in that 
of the back, he should sit up in bed, the body slightly bent for- 
ward, the arms folded, and the back turned toward the examiner. 



DIAGNOSIS. 293 

If the patient be sitting up, it is better to rest upon one knee than 
to stoop, in the examination of the anterior and lateral parts of the 
chest. 

In immediate auscultation, the patient should be sitting, either 
in bed, or upon a chair ; the physician, standing beside him, applies 
the same ear successively over the whole anterior thoracic region, 
to the right and left, at corresponding altitudes ; the right ear 
should be employed if he stand on the patient's left hand, the left, 
if on his right, so that the slightest difference presented by the aus- 
cultatory phenomena in corresponding points of the lungs or pleu- 
rae may not escape observation. The patient's arm being next 
held in an elevated position, the physician applies his ear to the 
axillary space of the same side and to different parts of the lateral 
thoracic region ; he passses to the other side to examine the dor- 
sal region, the opposite axilla and corresponding side of the chest. 

Acuteness of the sense of hearing is an important condition in 
the practice of auscultation, and the inequality of this sense, in the 
two ears, may be very troublesome to the auscultator, especially 
when the phenomena are indistinct. On this account, when both 
ears are not equally sensible of sound, (and this is perhaps the 
most common case,) the physician should employ exclusively the 
most acute in auscultation, and for this purpose he should stand 
successively on the right and left of the patient, so that he may 
examine with the same ear the anterior and posterior thoracic re- 
gions. 

Whatever be the mode of auscultation employed, the respiration, 
cough and voice are successively examined, in all the points to 
which the ear or the stethoscope is applied. We generally com- 
mence by listening to the natural respiratory murmur, that is, the 
patient respiring in his usual manner and with no more than ordi- 
nary muscular force and rapidity. We thus ascertain the strength 
or feebleness of the respiratory sound, whether it be soft, or rude 
in character, and the rales by which it is accompanied in the alter- 
nate movements of inspiration and expiration, whose duration also 
is observed. If we do not distinctly perceive the respiratory 
murmur, we desire the patient to breathe more fully or rapidly, 
as if sighing; also, to cough, for, in certain cases, it is only during 
the long inspirations which precede, or follow the cough, that we 
distinguish the fine, dry crepitus, or the bronchial respiration of 
pneumonia. One or two questions should be asked him. that we 
may ascertain whether the voice have a ringing character. In 
auscultation of the anterior thoracic region, the patient should be 
desired to turn the head away from the auscultator. This pre- 
caution always has the advantage of avoiding the inhalation of his 
breath, and facilitates auscultation of the voice. It is absolutely 
necessary in immediate auscultation of the anterior and superior 
thoracic regions, it being very inconvenient to apply the head to 
those parts, except the patient turn his own in the opposite direc- 
tion. 

8. Exploration with Sounds and Probes. — Sounds and probes 
25* 



294 DIAGNOSIS. 

have always been employed in tracing the course of fistulous 
ulcers, and the lesions of parts situated beneath these fistulse, par- 
ticularly the bones and cartilages; it is by means of metallic 
sounds, also, introduced into the bladder, that we discover the pres- 
ence of calculi, a shock being transmitted, by means of the instru- 
ment, to the hand which directs it. For the purpose of ascertain- 
ing the form, degree, and exact seat of strictures in the urethra, 
soft bougies have been introduced, capable of receiving and retain- 
ing the form of the parts with which they are for a time kept in 
contact, and it has been supposed that the resulting impressions 
represent accurately the lesions existing in the urethra. But expe- 
rience has shown that this mode of exploration does not merit all 
the confidence which some surgeons have too hastily ascribed to 
it. Flexible sounds are still employed in certain diseases of the 
rectum and oesophagus, for the discovery of foreign bodies or stric- 
tures not within reach of the finger. But the signs which may be 
deduced from the difficulty experienced in passing these instru- 
ments, have less value than those furnished by the introduction of 
the finger. 

9. Exploration by Specula. — Various instruments have been 
imagined for the examination of deep-seated organs, to which the 
name speculum* has been given : their purpose is to enable the 
physician, bloth to discover, by the eye, the many alterations which 
without their aid would be inaccessible to vision, and also to ap- 
ply to the diseased parts the different remedies required. 

Specula generally consist of hollow cylinders, with or without 
the central shaft intended to render their introduction more 
easy, and which is removed after the instrument itself is intro- 
duced. This shaft is indispensable when the speculum is used 
for the examination of a passage closed by a sphincter, as the rec- 
tum ; it has hardly any advantage in the contrary case, especially 
in examinations of the vagina and uterus. The form of specula 
has been almost infinitely varied, but these numerous varieties 
depend upon two principal conditions; one class are made entire, 
and represent a conic cylinder, others consist of several pieces, 
which glide upon one another so that the instrument may be as 
small as possible when introduced, and that after its introduction 
it may be so far expanded as is compatible with the construction 
of the parts to be examined, and as much as the examination de- 
mands. The four-bladed speculum seems to us far preferable to 
all the others in examinations of the uterus, and even of the rec- 
tum ; it has. moreover, this advantage, that we can, if necessary, 
detach one or two blades, for the better inspection of one side of 
the passage we examine. The two-bladed speculum is nearly ex- 
clusively used for the auditory canal. It is of great service in the 
diagnosis of various affections of which the tympanum is the seat. 
It has the advantage of straightening the curves of the meatus au- 
ditorius extemus, and rendering more easy and complete an 

* Mirror. 



DIAGNOSIS. 295 

examination, which might, it is true, be made without the instru- 
ment. 

The speculum intended for exploration of the rectum {speculum 
ani), is but rarely employed ; its introduction is generally painful, 
and the impossibility of giving a sufficiently large diameter for 
the requisite admission of light to the parts exposed, without caus- 
ing too severe suffering to the patient, restricts the number of cases 
in which it is useful, to those in which the disease is near the 
anus ; the vegetations, fissures or perforations so often occurring 
in this portion of the intestine, can be observed by means of this 
instrument. 

In uterine affections the speculum is far more frequently used, 
and its application is much more advantageous. The diagnosis of 
diseases of the cervix uteri has been much facilitated by its em- 
ployment; lesions of this part can thus be appreciated by the eye, 
and their progress traced as readily as that of external affections. 
Granular metritis, a very frequent and unimportant disease, ranked 
by some surgeons (quite improperly, as we think) among the 
most dangerous of uterine diseases, under the term ulcerations, 
remained nearly unknown until the period when the speculum 
was employed. By means of this instrument, certain small, red 
agglomerated elevations have been discovered around the margin 
of the uterine orifice, forming by their union a circular or oval 
patch, well circumscribed, resembling the raspberry in color and 
inequality of surface, and very easily distinguished by these two 
conditions from the healthy portion of the os tinca3. Since the dis- 
covery of this affection by the speculum, the touch, previously un- 
able to appreciate it, has furnished us with a sign by which, at 
present, we succeed in recognizing, or at least, are led to suspect 
it. If, when examining the surface of the os tinea? with the ex- 
tremity of the finger, we find, within and around the uterine 
orifice, a soft and somewhat uneven surface, imparting a sensa- 
tion comparable to that occasioned by touching the fabric known 
by the name of Utrecht velvet, while the eccentric portion of the 
os tincae is firm and smooth, the existence of this granular affec- 
tion can hardly be doubted, and we should immediately have 
recourse to the speculum to verify the diagnosis. The speculum 
enables us, moreover, to ascertain the nature of the liquid, fre- 
quently viscous and transparent, which escapes from the uterine 
orifice; we can also perceive, (especially if the instrument be 
slowly withdrawn and sufficiently expanded,) the alterations in 
the color, surface, and secretions of the vaginal mucous membrane. 

The introduction of the speculum into the rectum and vagina, 
requires certain precautions. Previous examination of the parts 
should be made with the finger, and in those cases only where 
this first examination has revealed, or led us to suspect certain 
lesions, and no obstacle to the introduction of the speculum exists, 
is it advisable to proceed to one which is yet more repugnant to 
the patient. The cerate carried by the finger into the rectum or 
vagina, renders the introduction of the speculum more easy, and 



296 DIAGNOSIS. 

this instrument is guided more accurately and carefully towards 
the diseased part when the ringer has already ascertained the seat, 
and, in some instances, the nature, of the affection. It is hardly 
necessary to add, that a considerable contraction of the vagina or 
rectum would be an obstacle, and sometimes a complete one, to 
this sort of exploration. In the examination of the uterus, the po- 
sition of the cervix being ascertained and sometimes rectified by 
means of the finger, the physician is more confident in regard to 
the direction which should be given to the speculum. If the touch 
discover cancerous degeneration of the vaginal or rectal parietes, 
we should abstain from introducing the speculum, or should use it 
with great circumspection ; for there are cases in which the dis- 
eased parts are so softened or attenuated, that the introduction of 
the instrument, and particularly the development of its valves, 
might cause a rupture whose consequences would be exceedingly 
serious. 

In all cases, even when the touch has not revealed any serious 
lesion of the parts into which the speculum is introduced, we should 
proceed to this examination methodically and carefully. The ex- 
ternal surface of the instrument, and above all, its extremity, as 
well as the central shaft, if thought necessary, must be covered 
with a thick coating of cerate or some other unctuous substance. 
In examination of the rectum, the patient should lie upon the side : 
care should be taken in the introduction of the speculum that it be 
effected slowly and at a moment when the sphincter is relaxed. 

In uterine examinations, the dorsal decubitus is preferable, the 
thighs should be flexed and separated, and the feet should rest 
upon a support some inches lower than the pelvis. In introducing 
the speculum, we should press moderately against the perinaeal 
surface of the vagina, until it passes the pubic arch ; the trans- 
verse line formed by the contact of the two vaginal parietes, which 
are seen in front of the instrument, indicates the direction which 
should be given to it. This line, receding before the instrument, 
conducts it to the os tincee, which is easily recognized by its rounded 
form and the absence of the rugae presented by the vaginal pa- 
rietes. The blades of the speculum should then be gradually ex- 
panded, taking care that they do not touch the os tincse, whose 
surface might be lacerated by them, and this organ comes fully 
into view at the extremity of the vagina. The mucus which fre- 
quently covers it may then be removed with pledgets of lint, 
applied by means of long forceps, and its color, form and volume, 
readily ascertained. If the day be dark, a candle may be placed 
before a teaspoon, whose concave surface will act as a reflector. 

Exploration of far more deeply seated parts, has been attempted 
by means of very complicated specula : among these are the in- 
strument proposed by Bambolzini, for the examination of deep 
cavities, particularly the stomach, and that invented by a mechan- 
ician affected with ulceration of the larynx, to enable his physi- 
cian, M. Trousseau, to inspect the cavity of this organ; that 
proposed by M. Segalas for the urethra and bladder, to ascertain 



DIAGNOSIS. 297 

the state of the mucous membrane and the actual existence of 
calculus, is of the same description. Hitherto, however, these 
ingenious inventions have remained nearly inapplicable. 

10. Examinations with the Microscope and Magnifying Glass. 
Although the unassisted eye suffices, in most cases, for the observa- 
tion of pathological phenomena we cannot doubt that the aid of 
those instruments, intended either to magnify very small objects, 
or to render visible, bodies wholly imperceptible to ordinary vision, 
possesses in all cases a certain degree of interest, and must, in 
some instances, furnish useful results. 

We have previously seen that the microscope was necessary for 
the discovery of certain substances contained in urinary deposits, 
and for the determination of their nature. It may be equally 
useful in appreciating certain alterations of the milk or of the 
blood corpuscles, and, especially, the presence of pus in the latter 
liquid, when the precaution has been taken to prevent its coagula- 
tion by depriving it of its fibrine. But it should be remembered that 
the microscope requires long practice ; this explains the often con- 
tradictory results obtained by different observers. For this reason 
we should not admit any observations as exact, unless they are 
verified a certain number of times, and by various persons accus- 
tomed to these researches. 

The magnifying glass {loupe) is more easily and generally 
employed : it enlarges objects sufficiently to enable us to recognise 
the presence of the acarus scabiei, and, of course, the head of the 
tape worm. With this instrument, also, certain superficial erosions 
of the cornea may be perceived, and the species of some cutaneous 
affections, about to declare themselves, be determined at their 
commencement, etc. 

11. Employment of Chemical Reagents in the Diagnosis of 
Disease. — There are some affections whose diagnosis is impossible 
without the aid of chemical agents: such is diabetes mellitus; and, 
also, that disease of the kidneys, in which the urine becomes albu- 
minous. The assistance of chemistry is necessary in these cases, 
not only to determine the nature of the disease, but also to follow 
it in its progress, and appreciate the changes effected in its inten- 
sity by time and remedies, and finally, to verify, in some cases, 
the complete disappearance of a malady too often rebellious under 
every kind of treatment. 

Among the diagnostic aids borrowed by medicine from chem- 
istry, there are some easily employed, and whose application should 
be familiar to every physician : such are tournesol * and turmeric 
paper, for determining the acid or alkaline quality of liquids, and 
nitric acid for detecting the presence of albumen in the urine, or 
for precipitating the coloring matter held in suspension by the bile. 
When, on the contrary, it becomes necessary to undertake a series 
of experiments which require much time and great experience, it is 
both proper and indispensable to entrust such researches to persons 
who have paid particular attention to these branches. 

* Heliotropium Europaeum. — Trans. 



298 DIAGNOSIS. 

Having stated the principal means of exploration which the 
physician should thoroughly understand in order to diagnose dis- 
ease, we shall in the next place describe the proper mode of exam- 
ining patients. 

§ III. Proper Manner of examining and interrogating Patients, 
for the purpose of Diagnosis. — When visiting a patient for the 
first time, the physician should commence by a rapid general 
examination. If the patient be up, his attitude and gait are the 
first objects of attention ; if he be in bed and nothing prevent, it 
is of service to uncover him completely, in order better to appreci- 
ate his strength, flesh, stature, and the various phenomena afforded 
by external appearance, such as certain eruptions, mutilations and 
deformities. This first examination is almost always sufficient for 
the recognition of recent or chronic diseases, and, in some cases, 
even for concluding that an acute has supervened upon a chronic 
affection. If, for example, we visit a patient at mid-day and ob- 
serve that redness of the face, increased heat, frequent pulse and 
prostration which belong to acute disease, the existence of this 
complication is, at any rate, very probable. 

Successive examination of the various regions of the body may 
furnish very important signs, not only in external, but also in in- 
ternal affections. In external diseases, simple inspection of the 
affected part is often sufficient to establish the diagnosis. In 
certain general affections, as scorbutus, syphilis, etc., the ecchy- 
moses, pustules, maculae and exostoses inform us, at a glance, of 
the nature of the disease. Cicatrices, also, deserve special atten- 
tion, particularly when they occupy the superior cervical and the 
inguinal regions. The former are almost always the result of 
scrofulous tumors ; the latter of a syphilitic bubo which has sup- 
purated. The existing disease may have some connection with 
one or other of these affections, and it is so much the more impor- 
tant that the physician be aware of their former existence, because 
many patients neglect or voluntarily refrain from mentioning 
them. * 

If the patient have lost a limb, a finger or one of the phalanges, 
the physician should never neglect to inquire the cause which 
rendered the loss of the part necessary. If it were white swelling 
which required amputation, this circumstance may have great 
weight in diagnosing an internal affection: if, for instance, the 
individual who has undergone this operation, present the symp- 
toms of chronic pulmonary catarrh with emaciation, we should 
fear the existence of tubercles in the lungs ; if his abdomen be 

*The cicatrix resulting from a burn, a blister or an ulcer of long standing, 
deserves also the physician's attention, less, perhaps, in a diagnostic than in a 
therapeutic point of view. It is well known that the suppression of an issue and 
the healing of a chronic ulcer are often followed by the development of some 
grave affection, which does not yield except on the re-establishment, natural or 
artificial, of these discharges ; the same is true of the maculae which succeed 
certain herpetic eruptions. 



DIAGNOSIS. 299 

harder and more voluminous than common, if the stools are fre- 
quent and liquid, it is to be feared that the mensenteric glands are 
the seat of incurable degeneration. Deformity of a limb or of the 
nose, etc., require the same questions. The physician should 
always know whether these deformities are congenital or acquired, 
and, in the latter case, what is the productive cause. 

When disease of very different character from those ordinarily 
manifested makes its appearance in an individual with congenital 
malformation, we should ascertain if this disease existed from 
birth, or whether it appeared a long time afterwards. In the 
former case, we may reasonably suppose that the unusual symp- 
toms complained of by the patient are owing to internal deformity, 
because observation has taught us that any deformity rarely exists 
alone : almost always there are several coexistent, and very often 
a faulty internal organization corresponds to that manifested ex- 
ternally. 

External appearance, moreover, supplies us with certain other 
valuable diagnostic signs, in those who work the metals. It is 
not very uncommon to see patients brought to the hospitals with 
convulsions, delirium or coma, and consequently unable to give 
any information relative to the causes of such affections, and in 
whom the red color of the hair, beard and eyebrows, or the pres- 
ence of a white powder at the root of the nails, make it almost 
certain that the illness is caused, in the former, by minium ; in the 
latter, by carbonate of lead. 

This hasty examination of the exterior of the body,* as we 
perceive, furnishes valuable diagnostic signs, especially when the 
physician wholly uncovers the patient. This we never fail to do, 
after the example of Corvisart and Bayle, in the male wards of 
the hospitals ; and also in private practice, whenever it is possible. 
Every one perceives, in part, at least, the advantages resulting 
from this mode of examining patients ; but in order thoroughly to 
appreciate them, it must be 'individually practised for a certain 
time. We have ascertained that it often enables us to dispense with 
a multitude of useless questions, and leads, in many cases, to a 
knowledge of circumstances, which, without its aid, would have 
remained undiscovered. 

* A new means of diagnosis of the tuberculous diathesis, has been lately an- 
nounced, derived from the external appearance {habitude exterieure). " When a 
child is observed with dark indes, colorless cheeks and darkish hair (the eyes 
often full and large, the eyelashes very long and close together), the forehead cov- 
ered with close-lying hair, sometimes almost down to the eyebrows, its arms and 
back from the hair of the head down between the scapulae, quite hairy, the hairs 
often being very thickly placed and dark in color, cachexia often being coexistent ; 
in nine cases out of ten, such a child is tuberculous ; either having tubercles 
already deposited, or liable to have them, in almost every organ of the body, the 
lungs especially. This hairy condition in a cachectic or unhealthy looking child, 
is a sign, generally speaking, of a constitution miserable in the extreme, saturated 
with scrofula." — (Dr. Wilshire. Med. Times, April 10, 1847.) Does not the 
confessedly existing cachexia, detract from the value of the concomitant alleged 
diagnostic sign, being in itself sufficient evidence of the tuberculous diathesis? 
Were these " hairy " children always stuffed with tubercles, when not cachectic in 
external appearance, the above would be an indubitable diagnostic sign. — Trans. 



300 DIAGNOSIS. 

Simultaneously with this rapid, but still careful external exami- 
nation, the physician commences his questions. Two important 
points here present themselves : the mode of questioning, and the 
order in which questions should be asked. 

When interrogating a patient, the physician should employ those 
terms only which are easily understood ; he should assure himself. 
if doubtful, that he has been well comprehended, by repeating a 
second and even a third time, if necessary, the same question in 
different terms from those first employed. He should so manage 
that the patient shall state of his own accord, as far as may be, 
all that is necessary to learn from him, and, for this purpose, his 
questions should be such that they cannot be answered by simple 
affirmation and negation. Without this precaution, the physician 
renders the patient liable to state his case far otherwise than if 
he had told it without restraint. 

It is equally necessary for the physician to pursue a regular 
course in questioning his patients; otherwise, he exposes himself 
to forget important questions and to repeat others, at any rate, 
needlessly, sometimes, injuriously to the patient,* and always to his 
own disadvantage. We say to his disadvantage ; for the patient 
who notices this, will think his attention distracted, and from that 
moment his confidence in him is impaired. The number of ques- 
tions necessarily varies according to the case. Generally, they 
should neither be too many nor too few ; it is nearly as important 
to omit those which can be of no service, as not to neglect those 
that are necessary ; the physician who wishes to know the minutest 
details, is more exposed, than another, to neglect essential points, or 
to forget them after having ascertained them. It is hardly neces- 
sary to add, that he who has not acquired the habit of seeing and 
interrogating patients needs to ask a great number of questions in 
order to form his opinion, while the experienced practitioner often 
attains this result, by the aid of signs furnished by the external 
appearance, and from limited information given by the patient or 
the assistants. So much the more important is it for the physi- 
cian, on account of his reputation, to proceed methodically in the 
examination of his patients, because his fellow-physicians form 
their opinion of him from such grounds. " A physician who listens 
to the interrogations made by another to a patient, judges imme- 
diately whether he is well informed ; and if so, he readily sees the 
reason of each question, why he passes from one to the other and 
the order in which they are asked. The most thoroughly informed 
physician," we should rather say, the most skilful, " is he who 
asks the fewest questions in diagnosing disease." f 

The following has seemed to us the best order to follow in 
questioning a patient seen for the first time. 

* The patient's interest sometimes requires that the number of questions should 
be very restricted : in diseases where silence is necessary, and particularly in in- 
flammations of the respiratory and vocal organs, as in haemoptysis, many ques- 
tions would always prove injurious. 

f Theses, 1808, No. 138. M. Fahard-Mont-Luc. 



DIAGNOSIS. 301 

1. We commence by asking his age, occupation, place of resi- 
dence, customary diet and usual habits of life ; whether he is 
habitually in good health or otherwise, and what illness he may 
have had. These questions are not always useful in diagnosis, 
but it is sufficient that they may be so in certain cases, to induce 
us never to neglect them. 

2. We next ascertain the period of commencement of the exist- 
ing disease; this should be determined with the greatest possible 
precision, especially in acute diseases : on this account the physi- 
cian should rarely content himself with the patient's first replies, 
particularly in hospital practice. Indeed, the lower classes disre- 
gard the functional disturbance which occurs during the first days 
of the disease, and do not consider themselves ill, except from the 
moment when they have left their work, or abstained from food, 
or from the day when they experienced severe pain. We must, 
then, if we would be exact, review all the functions from the day 
when the slightest disturbance occurred, to the moment of exam- 
ination. 

In chronic diseases, as we have elsewhere seen, the transition 
from health to sickness is almost always insensible, and it is often 
difficult to determine, even approximatively, the period when the 
disease commences. The external appearance of the patient is 
then often at variance with his replies ; it announces a disease 
already of long standing, while he complains only of some days 
or weeks of indisposition. It is generally easy to form a cor- 
rect opinion, by asking the patient himself, or those who reside 
with him, whether previously to the period to which he refers the 
commencement of his disease, he did not experience some indispo- 
sition, some diminution of appetite, strength or flesh. 

By the following questions, we endeavor to ascertain if the pro- 
gress of the disease has been slow or rapid ; if there have been 
sudden exasperations or gradual increase ; if the symptoms have 
been the same from the invasion ; if they have persisted without 
interruption, or have been manifested at intervals ; whether some 
of those originally observed have disappeared, and whether others 
have supervened. When the patient is confined to his bed, we 
should not forget to inquire since when, and how soon after the first 
appearance of the symptoms, he has been obliged to keep his bed. 
All commemorative circumstances are highly important in diag- 
nosis : in many diseases, indeed, and particularly in those whose 
diagnosis is somewhat obscure, it is quite as much upon the suc- 
cession of antecedent symptoms, as upon the concurrence of those 
actually present, that the physician's opinion may be founded. 
Unfortunately, many patients are not in a condition to give a clear 
statement of previous occurrences, and the physician is deprived 
of the information which might have been supplied by an accu- 
rate relation. When the patient's age or the disturbance of his 
intellectual faculties unfit him for replying to w our questions, we 
must rely upon the attendants. 

3. When all the preceding details are known, we pass to the 
26 



302 DIAGNOSIS. 

examination of the existing symptoms, which generally supply the 
most important diagnostic signs. 

We first inquire if the patient has any pain ; if so, we ascertain 
its situation. We should not rest satisfied with knowing that it is 
seated in the stomach or in the cardiac region, etc. ; the vague sense 
of these expressions, as employed by persons unacquainted with 
medicine is too well known : we request the patient to point out 
with his hand the place where the pain is seated, and also, if it 
extend over a considerable surface, to circumscribe it and trace its 
course ; we inquire if it is superficial or deep-seated, continued, pe- 
riodical or transient ; if its intensity be uniform, or if it increase and 
diminish at intervals, and under what influences ; if it be accom- 
panied by a sensation of heat or cold, of weight, etc. ; we ascer- 
tain thoroughly the effect of pressure upon this pain, and ask the 
patient to what it may be compared. 

We next notice whether there is any change in the color, vol- 
ume, form and consistence of the affected part. This examination 
often requires the concurrence of the sight and touch ; it should be 
made with the most scrupulous attention, and can never be omit- 
ted without disadvantage. We also ascertain if any unusual pul- 
sation or fremitus exist in the painful part, and, in certain cases, 
whether the natural resonance on percussion is preserved. 

The three great splanchnic cavities present very different condi- 
tions in regard to exploration, relative to the various degrees of re- 
sistance offered by their envelopes, and also to the number and 
importance of their contained viscera. The cranial cavity being 
entirely surrounded by osseous walls, the enclosed parts are, as we 
may say, removed from our explorative means, and protected also 
from the action of external objects likely to prove injurious. It is 
in early infancy only, or from the results of diseases which have 
retarded ossification, or more or less completely destroyed a por- 
tion of the bony parietes of the encephalon, either suddenly or 
gradually, that the physician can see and touch the organs within, 
naturally inaccessible to direct explorative means, and whose dis- 
eases we can only appreciate from the supervening functional dis- 
turbance; the difficult diagnosis of cerebral disease is thus ex- 
plained, a diagnosis so difficult, that notwithstanding the very 
remarkable works published upon this subject during the last 
twenty years, the physician who does not wish to hazard his opin- 
ion, is frequently obliged to be extremely reserved in regard to the 
diagnosis of a cerebral affection, given at the patient s bedside. 
This uncertainty, however, does not ordinarily regard the existence 
of the lesion, but its peculiar form; the cranium, containing but a 
single viscus and its enveloping membranes, presents in this re- 
spect favorable conditions for diagnosis, which compensate, in some 
measure, for the difficulties resulting from the arrangement of the 
investing tissues. 

The thoracic parietes, formed both of osseous and soft parts, are 
so disposed, that while they prevent the application of some of our 
direct means of exploration to their contained organs, they still 



DIAGNOSIS. 303 

admit many, by whose aid we can appreciate, and, as it were, touch, 
the greater part of the material organic lesions ; they are suscepti- 
ble of dilatation and contraction, either complete or limited, and 
these changes of volume afford ns some valuable signs. But while 
exploration of this region meets with fewer obstacles, the greater 
number of contained organs renders it more difficult to determine 
the seat of the disease. 

Lastly, the nature of the abdominal parietes which are formed 
posteriorly by the bony column which supports the trunk of the body, 
and elsewhere by fleshy tissues, renders every kind of exploration 
possible. Bat the number of organs contained in this cavity is far 
greater than in the two others : many among them concur in the 
same function, and from this very fact, the determination of the 
seat of disease presents more difficulties and is more frequently un- 
certain. We shall summarily state the proper method of examin- 
ing each of these three great cavities, either as a whole or in re- 
gard to any of their component parts. 

A. If the head be affected, it is sometimes useful to examine that 
portion of the cranium where the pain is felt, to ascertain if there 
be any partial tumefaction, and particularly, oedema and tender- 
ness of the scalp, characteristic signs of erysipelas of this part; 
also if the bony parietes be intact, if the sutures are in their natural 
condition, etc. 

We shall not attempt, in this place, to review all the symptoms 
which may be presented by the numerous organs enclosed within 
the cranium or situated upon the face. We shall restrict ourselves 
to the statement, that pain in the head and certain grave functional 
disorders of the encephalon, as delirium and convulsions, are far 
more frequently the indication of lesions in organs more or less re- 
mote, or the effect of certain deleterious agents, among which 
should be mentioned the virus of eruptive fevers, than the result 
of actual cerebral disease. We shall hereafter reconsider this point 
when treating of sympathetic phenomena, considered in their rela- 
tion to diagnosis. 

At present we merely observe, that pain, when confined to the 
right or left side of the head, hemicrania, properly so called, is 
almost constantly owing, either to a lesion of the corresponding 
cerebral hemisphere, or of its membranes, or, far more frequently, 
to disease of some of the parts included in the same half of the 
face, particularly the nasal fossse. the frontal and maxillary sinu- 
ses, the teeth, the ear, or the eye. 

B. When the vertebral column is the seat of pain, or when re- 
markable disturbance of the nervous action of the spinal marrow 
directs attention to that point, the spinal region should be exam- 
ined, the patient either standing, or lying upon the abdomen. We 
are thus enabled to discover the various deviations and curvatures 
of which the spine may be the seat, the projection of one or more 
vertebrae accompanying Pott's disease, etc. Great importance has, 



304 DIAGNOSIS. 

of late, been attached to the pain (more or less severe) produced in 
a limited portion of the vertebral column by pressure, made suc- 
cessively, with one or two fingers from the atlas to the sacrum, and 
this phenomenon has been cited as capable of revealing the ex- 
istence of a lesion of the spinal marrow, or of its membranes, in the 
part corresponding to the seat of pain. The thickness of the parts 
comprised between the spinous processes and the spinal marrow, 
the slight depressibility of the vertebrae, and the unequal projec- 
tion of the different spinous processes, lead us to suppose that the 
importance of this sign has been much exaggerated, and that new 
facts are necessary in order to determine its value. The same 
may be said of the hot sponge which Copeland* has proposed to 
pass along the spine, and which, it is asserted, would cause a 
burning sensation in that point only where the medulla was af- 
fected. 

C. If the ear be painful, or if any remarkable lesion of the audi- 
tory sense arrest the physician's attention, the meatus auditorius 
externus should be examined, and in certain cases, it should be 
ascertained whether the meatus auditorius internus be permeable. 

The examination of the meatus auditorius externus is not very 
difficult ; it is often sufficient to straighten the passage by draw- 
ing the concha upwards and outwards, and thus gain a complete 
view of the whole internal surface, and even distinguish with suf- 
ficient precision the membrane of the tympanum, especially if 
direct solar light be introduced. If simple traction of the concha 
be not sufficient to bring the interior of the auditory canal properly 
into view, we employ the small instrument called speculum auris, 
whose two movable blades, separating after their introduction, 
straighten and enlarge the passage, and allow the eye to distinguish 
the different changes occasioned by disease, either in the mem- 
brane itself, or in the matter secreted by it ; ulcerations and perfo- 
rations of the tympanum are equally easy of discovery by means of 
this instrument. 

Exploration of the meatus auditorius internus, which has been 
icvived by the exertions of Dr. Deleau, presents considerable dif- 
ficulty; on this account it is hardly ever employed, except by the 
small number of physicians who make the diseases of the ear, and 
their treatment, the object of special study. This exploration is 
performed by means of a small sound of metal, or preferably, of 
gum elastic, introduced into the nasal fossae and directed so as to 
penetrate into the Eustachian tube. The obliteration of this canal 
is a frequent cause of deafness. 

D. Certain peculiar phenomena, as the nasal alteration of the 
voice, difficulty of breathing through the nose, discharge of puru- 
lent or sanious matter from the anterior or posterior openings of 

* Observations on the Symptoms and Treatment of Diseases of the Spine. Lon- 
don, 1815. 



DIAGNOSIS. 305 

the nasal fossae, or a fetid odor proceeding from these cavities, may- 
require an examination which is managed as follows : the patient 
is turned towards the light, the head thrown backwards, one of the 
examiner's fingers pressed upon the lobe of the nose for the pur- 
pose of expanding the nostrils, or, preferably, a pair of dressing 
forceps is introduced, the separation of whose branches allows of 
a more complete inspection of these anfractuous cavities. We 
may, moreover, by means of an elastic sound, or of Belloc's instru- 
ment, sometimes ascertain the presence of a foreign body not dis- 
cernible by the eye. 

E. If the disease occupy the isthmus of the fauces, or the supe- 
rior opening of the larynx or oesophagus, the following is the mode 
of examination. 

1. For the examination of the isthmus of the fauces, we cause 
the patient to open the mouth widely : we depress the tongue with 
the index finger, with the handle of a spoon, a spatula or the in- 
strument called tongue depressor * whose concave surface is 
accurately adapted to the convexity of this organ, and we expose 
the velum palati and its pillars, the uvula, tonsils and posterior 
part of the pharynx. In some persons, the epiglottis itself may be 
seen behind the base of the tongue, and, when inflamed, may come 
entirely into view, resembling a cherry with a median fissure. 

We ascertain the alterations in these various organs, in respect to 
color, volume, moisture or dryness, the nature of their secretions, 
the coats or false membranes, granulations, ulcerations, and perfo- 
rations which they may present. Certain individuals have the 
faculty of lowering the base of the tongue sufficiently, by muscular 
action alone, to expose completely those parts not visible in the 
majority of persons except by powerful depression of that organ; 
in them the inspection of the posterior fauces is as easy as that 
of the gums and tongue. 

Some diseases, as angina tonsillaris and mercurial stomatitis, 
when at their height, entirely prevent the depression of the lower 
jaw, and, consequently, completely frustrate this kind of explora- 
tion. In these cases, where the lesions cannot be seen, we some- 
times succeed in ascertaining, although with difficulty, by means 
of the index finger introduced into the mouth, between the slightly 
separated teeth, or in a space where they are wanting, increased 
volume of the tonsils, and their consistence, and occasionally to dis- 

* The speculum oris (lately constructed by the French instrument-makers) com- 
bines the speculum with the depressor linguae. ; it consists of the latter, projecting 
from a hoop of the same metal, (usually the German silver, or the amalgam 
called " maillechort,") which is pierced with two or three apertures correspond- 
ing to the same number of buttons for retaining it at different graduations of its 
circumference, thus adapting it to the various sizes of the mouth in different indi- 
viduals, and maintaining it permanently expanded during its insertion, thereby 
avoiding the signal inconveniences experienced when a spatula or the handle of a 
spoon are used for depressing the tongue. A far better view of the buccal cavity 
and posterior fauces is also obtained. — Trans. 

26* 



306 DIAGNOSIS. 

cover an abscess, which has in some instances been ruptured by 
simple pressure of the finger. 

By means of the ringer introduced as far as possible into the 
mouth, in certain cases of angina oedematosa [oedema, of the glot- 
tis], we discover the tumefaction of the membranous folds extend- 
ing from the epiglottis to the arytenoid cartilages and circumscrib- 
ing the superior opening of the larynx. This examination excites 
in some patients so strong contraction of the pharyngeal muscles 
and so much retching, that it is wholly useless. 

Exploration of the oesophagus and of that portion of the pharynx 
not attainable by the finger, must be practised with the oesopha- 
geal tube, which is introduced through the nasal fossae, or prefera- 
bly, by the mouth. We thus discover or suspect, in some cases, 
from the degree of resistance encountered, the existence of stricture 
or the presence of a foreign body, and determine their situation. 

F. When local symptoms are manifested in the chest, we should 
endeavor to determine whether the disease occupies the parietes of 
the thorax, or the organs contained within it, and in the latter case, 
whether it be seated in the organs of respiration or circulation. 
To obtain this result, the conformation of the chest should be ex- 
amined (p. 91), and percussion and auscultation employed, to ascer- 
tain whether the functional disturbance is connected with some 
material alteration of the organs contained in this cavity, and if 
necessary, to these results should be added those obtained by men- 
suration. We have previously mentioned the signs furnished by 
each of these modes of exploration ; we will here enumerate, very 
briefly, the diagnostic signs acquired by the comparison of these 
three orders of phenomena. 

The diminution or permanent absence of the respiratory mur- 
mur, without alteration either of the conformation or resonance of 
the chest, usually indicates that some internal or external body 
closes or compresses the trachea, and prevents the passage of air 
into the pulmonary vesicles. According as these phenomena man- 
ifest themselves in a limited portion, or over the entire surface 
of one side of the chest, or even of both, we conclude that the 
obstruction to the passage of air, occupies, in the first case, one of 
the bronchial divisions ; in the second, the principal bronchus ; in 
the third, the trachea or larynx. 

If the diminution in the strength of the respiratory murmur be 
accompanied by increased resonance and dilatation of the thoracic 
parietes ; if these phenomena are particularly manifest in the 
space included between the clavicle and the mamma, their con- 
currence reveals the existence of pulmonary emphysema. 

Entire absence of the respiratory murmur over one side of the 
chest, with tympanitic resonance and dilatation of the parietes, 
generally indicates the existence of pnewmo-thorax. If amphoric 
respiration and voice be added to the three previously mentioned 
phenomena, we can no longer doubt that there is a communication 
between the pleural cavity and some bronchial branch, from which 



DIAGNOSIS. 307 

communication pneumo-thorax results. If metallic tinkling and 
gurgling on succussion be added to the former symptoms, and if 
the sound become flat at the base of the chest, over a space grad- 
ually extending upwards, hydro-pneumo-thorax undoubtedly ex- 
ists. 

If we find simultaneous diminution of resonance and feebleness 
or absence of the respiratory murmur, there is, necessarily, either 
alteration of the pulmonary parenchyma, rendering it less per- 
meable to the air, or interposition of some solid or fluid body, 
which prevents both the transmission of the respiratory murmur, 
and also the penetration of air into the compressed lung. 

If the sound be flat over one entire side of the chest, if the res- 
piratory murmur and the resonance of the voice be null in that 
part, there is certainly liquid effusion into the pleural cavity, par- 
ticularly if mensuration discloses a remarkable increase or dimi- 
nution of volume in the affected side ; in the latter case, absorption 
of the fluid is taking place. If the sound be obscure or flat in one 
part of the chest only, the corresponding changes are generally 
less marked, and, when present, almost always imply an organic 
lesion of a chronic nature. If this obscurity of sound be at the 
superior part of the chest, and in the sub-clavicular region espe- 
cially, if there be a depression in that point more readily appreci- 
able by the eye than by mensuration, if the respiratory murmur 
be feeble, expiration prolonged and somewhat rude, and particu- 
larly if some moist crepitus be heard, if the voice is more resonant 
there than on the opposite side, we must conclude that tubercular 
affection of the lungs exists. The flat sound, accompanied by 
bronchial respiration and resonant voice, may depend upon pul- 
monary induration or slight pleuritic effusion. In these two cases, 
mensuration is of no service, but generally, the resonance of the 
voice has a jerking character in pleurisy; the contrary is the case 
in pneumonia. In the latter affection, some crepitus is nearly 
always caused by the cough, in certain points where bronchial 
respiration is heard, and this constitutes a valuable diagnostic 
sign. Partial pleuritic effusion constantly occupies the lowest part 
of the chest; pneumonia may be manifested in any portion. 

Dulness on percussion, with absence of respiratory murmur and 
resonance of voice, when limited to any part of the chest except 
the precordial region, almost always denotes a circumscribed 
pleuritic effusion, the fluid being in moderate quantity {d 1 une 
ccrtaine epaisseur) ; sometimes, a tumor or partial splenization of 
the lung. 

Circumscribed and chronic effusion, and tumors, may cause a 
partial protrusion or prominence of the thoracic parietes. which is 
never produced by splenization. Tumors are almost always seated 
in the superior portion of the chest; most frequently they are 
formed by the dilatation of the large vessels ; they then present 
pulsations isochronous with those of the heart, abnormal sounds 
and other characteristic signs. The distinction between circum- 
scribed effusion and pulmonary splenization is often difficult: but 



308 DIAGNOSIS. 

in one case, the possibility of changing certain conditions relating 
to the effusion by varying the attitude of the patient, and the 
moderate intensity of the dyspnoea and febrile action ; in the other, 
(splenization,) the presence of pneumonic sputa and the gravity 
of the general symptoms are phenomena, which, in most cases, will 
supply the deficiency of signs furnished by exploration of the 
chest ; effusion, moreover, constantly occupies the base of the chest ; 
splenization may occur in any portion. 

A flat sound on percussion, when confined to the cardiac region, 
indicates an affection of the heart, or of its envelopes. We should 
suspect pericarditis, if the affection be recent, if the dulness has 
been rapidly developed, if the sounds of the heart are deep and 
obscure ; if opposite phenomena are observed, our diagnosis should 
be hypertrophy, particularly if there be also considerable promi- 
nence of the precordial region, strong impulse and very distinct 
bellows murmur. 

G. When the symptoms are referred by the patient to the ab- 
domen, that part should be thus examined. The patient should 
assume the dorsal decubitus, the head be raised by a pillow, the 
thighs flexed upon the pelvis, the legs upon the thighs, and the 
knees slightly separated. We ascertain by ocular inspection, or 
by means of the hand, the changes of form and volume which 
may be presented, either over the entire surface of the abdomen, 
or in one or more points, especially in those where hernia or simple 
dilatation of herniary apertures may exist. Pressure and palpa- 
tion are next resorted to, conformably to the foregoing rules ; we 
percuss, and if necessary, employ mensuration and touch, should 
any circumstance indicate the utility of these explorative means. 
In those cases where the abdomen is distended by an enormous 
quantity of serous fluid, it often happens that we cannot exactly 
judge of the condition of the viscera, or discover the lesion which 
causes the dropsical effusion until after the evacuation of the fluid 
by tapping. 

Many important diagnostic signs are furnished by abdominal 
exploration. It alone, enables us to ascertain the accumulation of 
serous fluid in the peritoneum, of gas in the intestines, and the 
various tumors resulting from hypertrophy or degeneration of the 
abdominal viscera. The latter are characterized by certain con- 
ditions with which we should be acquainted, because they consti- 
tute actual pathognomonic signs ; thus, the liver and spleen almost 
constantly preserve their original form in the different diseases 
which augment their volume, and no other part, when morbidly 
enlarged, assumes the form of the liver or spleen ; consequently, 
whenever we discover in the abdomen, a tumor occupying the 
right hypochondriac and the epigastric region, extending upwards 
beneath the ribs, and whose inferior border is firm, angular, run- 
ning transversely, but more often obliquely, from left to right, and 
from above downwards, we may be sure that it is formed by the 
liver. A tumor which occupies the left side, extending somewhat 



DIAGNOSIS. 309 

beyond the false ribs, whose form is a segment of an ovoid, whose 
internal border is rounded and angular, and vertical in its direc- 
tion, must be formed by the spleen, particularly if no general 
transposition of the viscera exist, of which an examination of the 
precordial region may convince us : if the heart be in its usual 
situation, we may, as a general rule, conclude that the liver and 
the spleen are so, likewise. The bladder in both sexes, the uterus, 
and, to a certain extent, the ovary in the female, present in their 
development, certain peculiarities of form and position, which 
admit of easy recognition, at least in the majority of cases. Tu- 
mors formed by masses of faecal matter in the large intestines, 
have a form similar to a string of beads {forme de chapelet), 
which generally renders their diagnosis easy. Those formed by 
the kidneys have no peculiar shape, and the depth at which they 
are seated, does not allow us to reach them, except they have 
acquired considerable volume. We may discover these tumors by 
seizing the sub-costal region with the whole hand, the thumb 
resting upon the lumbar portion, and the fingers upon the side. 
Tumors developed in the stomach and intestines are never uniform 
in volume, form or seat, and are frequently movable. Those 
of the pylorus are found, in certain patients, very far from the 
region commonly occupied by this extremity of the stomach ; they 
have occasionally been discovered near the umbilicus, and even in 
the right iliac fossa, nearly in contact with the anterior, superior 
spinous process of the ilium. The iliac fossae are very frequently 
the seat of phlegmonous tumors, to which the attention of physi- 
cians has been particularly directed by the researches of Dance, 
and MM. Melier, Meniere and Grisolle. Lastly, the abdomen is 
sometimes the seat of pulsative tumors, some of which are formed 
by aneurismal arteries, others derive their pulsation from a neighbor- 
ing artery. Auscultation should be practised in these cases, as well 
as in those where there is doubt as to the existence of pregnancy. 
It is also interesting (as is evident from the researches of many 
English physicians, particularly Bright, Corrigan, Beatty and 
Stokes) in certain forms of peritonitis, especially in those where 
the abdomen contains a more or less resistant tumor; in these 
cases a slight friction sound is heard, indicative of the develop- 
ment of false membranes upon the internal surface of the peri- 
toneum. 

H. In scrotal examinations, it is important to ascertain whether 
the disease, whatever be its nature, occupies the envelope or the 
contained organs, and among the latter, whether the epididymis, 
testicle or tunica vaginalis are affected; to pressure and palpation, 
should be added the weight [act of weighing, " ponderation" ] of 
the tumor, and we should ascertain particularly, whether it be 
transparent, by placing it before a bright light ; tumors of the 
testicle are heavy and opaque, hydrocele is light and transparent; 
an explorative puncture (as it is called) is sometimes indispensa- 
ble, to render the diagnosis positive, when examination of the 



310 DIAGNOSIS. 

tumor will not justify us in asserting that its contents are fluid. 
In certain cases of scrotal enterocele, percussion elicits a clear 
sound, and assists our diagnosis. 

T. In cases where the rectum is the seat of the local symptoms, 
in either sex, or the organs of generation in the female, ocular 
inspection is necessary ; when the disease is external, the anus or 
vulva should thus be examined, the soft parts which surround each 
orifice being separated as far as is necessary; when internal, the 
finger or speculum should be introduced into the rectum or vagina, 
according to the rules and precautions previously indicated. 

J. The examination of the limbs is not always so simple as 
we might, at first, suppose. Not to mention the difficulty 01 diag- 
nosis, in certain cases of fracture without displacement of the 
fragments, and of some chronic dislocations, we would point out, 
as worthy the attention of the physician, the frequently trifling 
difference in the volume of the limbs, in their length, contractility, 
sensibility, heat, freedom and extent of motion, and in the volume 
and direction of the bones which support them. Partial or general 
swelling of the limbs, the various tumors of which they are the 
seat, either in their continuity or contiguity, and the external lesions 
to which they are even more exposed than the body, supply the 
physician with numerous phenomena to be discovered only by 
examination of the affected part. 

Having finished the examination of the region to which the pain 
is referred, we should ascertain the functional condition of the 
corresponding parts. For example, if the patient complain of 
pain in the chest, we examine the respiration in regard to its fre- 
quency, its equality and the mode of dilatation presented by the 
thorax; we learn whether there be cough ; and if there be sputa, 
we examine them. Before passing to general symptoms, which 
are less interesting, we should ascertain the functional condition of 
those organs more particularly sympathizing with the affected 
parts. Thus, when an acute pain in the lumbar region and along 
the course of the ureters, with suppression or alteration of the 
urine, leads us to suspect inflammation of the kidney, the local 
symptoms having been examined, we should inquire if there be 
retraction of the testicles and vomiting, because these two sympa- 
thetic phenomena are important signs of nephritis. The same is 
true of vomiting in peritonitis, etc. 

If the patient experience no local pain, and complain only 
of some functional disturbance, as cough, diarrhoea, partial debil- 
ity, etc., we first examine everything in any way connected with 
the function principally involved ; the general symptoms are after- 
wards considered. 

In those cases were the patient complains only of general indis- 
position without particular pain, of universal derangement of the 
functions without any marked disturbance of any one in particu- 
lar, we examine them all in the order we have followed in the 
general account of symptoms. 



DIAGNOSIS. 311 

The physician should at first direct his attention to the expres- 
sion of the patient's physiognomy, and to his attitude. He should 
then endeavor to appreciate the muscular force, either by questions 
or by certain movements required of the patient. If the voice 
seem unnatural, he learns from the assistants what changes it 
may have undergone; he afterwards inquires into the condition of 
the various sensations, the moral affections, the character of the 
patient, his intellectual faculties, and his sleep; after which he 
examines, successively, the nutritive functions. 

The interior of the mouth, and particularly the tongue, is next 
examined ; the patient is asked if he is hungry or thirsty, if degluti- 
tion be free, if he experience nausea or eructations; if he still takes 
food, and in what quantity, if digestion be easy, if uncomfortable 
sensations, oppression or somnolency occur after eating ; if there 
are borborygmi ; the physician should ascertain whether the ab- 
domen be supple, the alvine evacuations regular, and what is the 
nature of the excretions. He next notices the respiration and the 
different respiratory acts, then the circulation, heat, exhalations, 
and secretions, and finally, if it be necessary, inquires into the 
state of the generative functions. 

In this complete review of the functions, the physician should 
endeavor to fix the period at which each symptom appeared, and 
the successive changes it has manifested from its appearance to 
the moment of examination. 

To the examination of symptoms, the difficult, and often un- 
fruitful, search for the productive causes of disease should always 
be added. The knowledge of causes, when it can be gained, con- 
firms or rectifies diagnosis in obscure cases, and is not without 
interest in others. Consequently, we should not neglect to ask 
whether the affection whose nature we endeavor to determine, be 
hereditary or acquired ; if this be the first attack or otherwise ; if 
it be owing to specific causes whose action is manifest, or to pre- 
disposing causes, whose action is uncertain ; if it have any con- 
nection with previous diseases, and what those diseases have been. 

The effect of remedial measures may also contribute to decide 
our opinion, particularly when the disease under consideration is 
of that limited number arising from specific causes ; the specific 
remedy employed, becomes, in such cases, a sort of touch-stone 
which reveals their nature. This is particularly observed in 
syphilitic affections, and in some obscure forms of intermittent dis- 
eases. In these cases, and in certain others also, diagnosis is 
almost entirely founded upon the knowledge of the cavse which 
has produced the disease. 

§ IV. Principal component Elements of Diagnosis. — If there are 
certain diseases whose nature is simple and whose effects are limited 
to the parts they occupy, as wounds, or fractures not presenting 
those conditions to which surgeons have quite improperly applied 
the term complication, it is otherwise in most affections, especially in 
those constituting the domain of medical pathology. Here, indeed, 



312 DIAGNOSIS. 

the disease is nearly always complex ; there is predominant lesion 
of one organ, simultaneously with lesions of all the others, or at 
least of those more particularly connected with the one principally 
affected. This more or less general disturbance of the organism 
sometimes precedes the local lesion, announces it and perhaps con- 
curs in preparing its development ; in other cases it is associated 
with it; both may appear simultaneously. In all these cases the 
disease is by no means simple, and the physician who sees in ery- 
sipelas or pneumonia, only the material lesion of the skin or pul- 
monary parenchyma, would not have an accurate idea or a thorough 
knowledge of either disease ; for such knowledge necessarily com- 
prehends, on the one hand, the seat and nature of the lesion, its 
extent and degree of intensity, and on the other, the accompany- 
ing symptomatic phenomena, local and general, their form, whether 
acute or chronic, the presence or absence of febrile reaction, the 
energy of that reaction, the period attained by the disease, the pe- 
culiar type it assumes, etc. ; these are, indisputably, so many con- 
ditions constituting indispensable elements of diagnosis, and should 
be carefully examined in this connection. 

When diagnosis is thus thoroughly considered, we see how in- 
complete and restricted was the opinion of certain physicians of the 
anatomico-pathological school, who founded their diagnosis of dis- 
ease entirely upon material organic lesions, so that, in their opinion, 
every thing depended upon determining what organ was affected, 
and in what manner. The ancients were more excusable, when, 
strangers as they were to the knowledge afforded by necroscopy, 
they saw, in disease, only the apparent functional disturbance, 
which, indeed, they observed with admirable sagacity. 

A. Determination of the Seat of Disease. — This includes several 
questions which will be successively considered. 

1. Which is the diseased organ. 2. To what extent is it affected. 
3. In certain cases, which of its elementary tissues is particularly 
diseased. 

1. Which is the diseased Organ? — The senses alone are suffi- 
cient, in a certain number of diseases, to inform us which is the 
affected organ ; in others this knowledge cannot be acquired, except 
by the aid of those signs which reason deduces from the phenom- 
ena furnished by the senses ; in still other cases, the seat of disease 
remains obscure through life, and sometimes even after the ne- 
cropsy has afforded us the most complete investigation, and one 
seemingly the most likely to dispel every doubt. 

When the disease is external, as herpes zoster or erysipelas, its 
seat is so evident, that unprofessional individuals can perceive it 
equally with the physician. The same is true of the numerous 
diseases of the skin, and of the majority of those seated near the 
point of union of the skin and mucous membranes ; conjunctivitis 
is recognised at sight, as also ulceration and puffiness of the lining 
membrane of the mouth, swelling of the tonsils, excrescences de- 
veloped near the nostrils, upon the glans penis, the vulva and 



DIAGNOSIS. 313 

around the anus. We may, moreover, as regards the ascertain- 
ing their seat by means of our senses, compare these diseases with 
certain affections in which the diseased organ, originally out of 
sight in one of the splanchnic cavities, as the thorax or even the 
cranium, causes absorption of their parietes by reason of its subse- 
quent morbid growth, and shows itself beneath the skin. Fungus 
of the dura mater and aneurism of the arch of the aorta, become, 
in this way, external diseases. Certain diseases of the abdominal 
viscera, may also be subjected to the touch, especially when they 
occupy the liver or spleen, which organs, as we have previously 
observed, almost always retain their form, whatever may be their 
increase of volume. As we have elsewhere remarked, by the in- 
troduction of the finger into the vagina or rectum we ascertain the 
seat of various affections, and, by the use of the speculum, vision 
assists the sense of touch. In nearly all cases of fracture, the de- 
formity of the limb, the mobility of the fragments and the distinct 
crepitation, are all phenomena clearly indicative of the seat of 
injury. 

There are, however, many diseases, particularly among those ap- 
pertaining to internal pathology, where the senses alone are insuf- 
ficient to determine what organ is affected. If the disease be one 
of that class which are of sufficient severity to terminate occasion- 
ally in death, and which present constant lesions on dissection, the 
comparison of the phenomena observed during life with the lesions 
discovered, after death, in analogous cases, generally enables the 
physician to declare without hesitation its seat, and the kind of 
alteration presented by the affected organ. When, therefore, in an 
unlimited number of cases, after a determinate series of symptoms, 
post-mortem examination reveals, in the same parts of the body, a 
lesion of constant occurrence, we reasonably conclude, that when- 
ever the same phenomena reappear, we shall find the same organ 
similarly affected. 

There are, however, certain diseases, some of which are severe 
and others of slight importance, for whose elucidation pathological 
anatomy furnishes us far less assistance. If the individuals affect- 
ed by them die, either from the actual disease or some coexistent 
affection, nothing is discovered explanatory of the previously ob- 
served phenomena, either because the accompanying lesions are 
not appreciable by our senses, or because the requisite attention 
has not, thus far, been devoted to researches of so delicate a nature. 
Many individuals die instantaneously, or in a very short time, with 
apoplectic symptoms, tetanic convulsions, and hydrophobic spasms ; 
some even die paralytic, and no lesion whatever is discovered at 
the necroscopy. If an individual affected with acute rheumatism, 
or some nervous disease, be attacked by another and a fatal mala- 
dy, in the majority of cases, no appreciable alteration is met with 
in the parts to which the pain was referred. Necroscopy has hith- 
erto proved insufficient to determine the seat of these diseases, and 
certain notions upon this point have been derived solely from the 
often contestable laws of physiology. 
27 



314 DIAGNOSIS. 

Physiology acquaints us with the functions proper to each of our 
organs. Disorder of a function leads us to admit a certain lesion 
in the organ to which that function belongs. Thus, when severe 
pain occurs without swelling, redness, or any other appreciable 
change in the affected part, we judge that the disease is seated in 
the nerves or brain, because they are the organs of sensibility. 
If this pain increase on motion, and diminish or cease by rest, if 
its intensity is constantly proportionate to the force of muscular 
contraction, we conclude that the affection is seated in the organs 
of motion, that is, the muscles. But here there is no absolute 
proof; the concurrence of the nerves and muscles being necessary 
to motion, it is difficult to distinguish whether the disturbing cause 
be in the muscular or nervous system, or in both together. This 
distinction is equally difficult in convulsive diseases, of which the 
muscles are the immediate agents, and in which the nervous sys- 
tem plays, incontestably, a great part. Our previous and future 
remarks upon sympathy will prove more clearly into what error 
we should be led, if we attempted, in all cases, to determine exactly 
which is the affected organ, from functional disturbance alone. 

The difficulty of fixing the seat of diseases becomes still greater in 
those characterized by general functional disturbance, without pri- 
mary local affection. We mean fevers, and especially intermittent 
fevers ; for if there still exist conflicting opinions among physicians 
in regard to the constancy and value of lesions in continued fevers, 
they are agreed in regard to the impossibility of determining the seat 
of disease in intermittent fevers. The external appearance is 
changed, the circulation, heat, digestion, secretions, sensations, 
sometimes even the intellectual functions, respiration, locomotion 
and the voice, are simultaneously affected for a certain number of 
hours, the disturbance ceasing with the paroxysm. Where in such 
a case is the seat of disease 1 Is it in the spleen, as some assert? In 
the stomach, the intestines, or the mesentery ? Is it in the nervous 
system generally, or in one of its divisions 7 In the blood or some 
other of the fluids which enter into the composition of the human 
body? All these opinions have had or still have their partisans, 
but none of them has been established upon a basis sufficiently 
firm to convince us of its truth. The interesting researches in 
pathological anatomy, made some years since by Dr. Bailly (too 
soon removed from science and society), in a country where inter- 
mittent fevers are sufficiently severe to terminate frequently in 
death, have left the question of the seat of intermittent fever unde- 
cided ; a disease in all other respects so well understood, that not- 
withstanding the obscurity which prevails in regard to this point 
of their history, it is, at present, of all the diseases to which man is 
subject, the one whose diagnosis is generally most easy, and whose 
treatment shows most incontestably the power of our art. So true 
is it that the most important thing in medicine, and even in diag- 
nosis, is not always, as has been asserted, to determine which is the 
affected organ, and how it is affected. 

2. The Seat of the Disease being known, what is its Extent ? — 



DIAGNOSIS. 315 

In those cases where the physician succeeds in discovering which 
is the diseased organ, it is desirable to determine to what extent it 
is affected. If we consider how much its extent influences the 
gravity of the disease ; what difference there is, for instance, be- 
tween erysipelas limited to one cheek, and that which occupies 
the face, and simultaneously the entire scalp ; between partial pem- 
phigus, and that which is nearly general; between variola discreta 
and variola confluens (for in the latter, it is, as it were, a simple 
difference in the extent of the affection, measured by the number of 
pustules); between inflammation limited to a single point in one 
lung, and double pneumonia; between partial peritonitis, a disease 
generally attended with little danger, and general peritonitis, which 
is most frequently mortal, we cannot misunderstand all the impor- 
tance which the question of extent should have, in deciding our 
opinion of a disease. 

The extent of those diseases which are seated at the surface of 
the body is easily perceived. In these cases, however, the affec- 
tion is not always confined to the skin. Many affections styled 
cutaneous, and particularly those depending upon a contagious 
principle, attack the skin and certain of the mucous membranes 
simultaneously, and. by the febrile action they excite, often produce 
lesions of considerable severity in the viscera themselves. 

It is generally difficult to determine the extent of the disease in 
internal affections; this difficulty, however, is not always insur- 
mountable. Thus the exploration of the abdomen often enables 
us to determine whether the liver is diseased throughout, or in one 
lobe only, also, to what extent the spleen is enlarged ; examination 
of the chest enables us to distinguish whether pleuritic effusion 
occupies a part or the whole of the pleura; if pneumonia, limited 
at first to a portion of the pulmonary parenchyma, invade daily 
a greater extent, and whether at a more advanced period it be- 
comes limited in its seat, and diminishes in intensity at the same 
time. Finally, there are certain cerebral affections, haemorrhage 
in particular, in which we can, to a certain extent, estimate the 
volume of the apoplectic clot, from the intensity of the symptoms, 
and consequently the extent of the rupture of the cerebral pa- 
renchyma. There is, then, a certain number of internal diseases, 
in which we can judge, approximatively at least, of the extent 
occupied by the material lesion. 

3. The study of the seat of diseases sometimes extends to de- 
termining which of the elementary tissues is primarily affected. 
But we should remember that this sort of research belongs to that 
molecular anatomy, in which imagination too often supplies the 
insufficiency of the senses, and whose results must be received 
with great circumspection. 

There are, however, some diseases of the skin whose special seat, 
whether in the mucous layer, or in the follicles, is now scarcely 
contested ; among these are acne, which seems to occupy the fol- 
licles exclusively, and those affections known by the name of ma- 
culm and ephelides, which, being characterized by alterations in th 



316 



DIAGNOSIS. 



color of the skin, can hardly occupy any other part than the mu- 
cous layer, in which the secretion of coloring matter takes place. — 
Every one, at the present day, is aware that in typhoid fever it is 
not the intestinal mucous membrane which is affected, but the 
follicles, either agminated or isolated, which lie between this mem- 
brane and the cellular coat, and which occupy particularly that 
portion of the ileum nearest to the coecum. But if we pass from 
the skin and mucous membranes to certain other organs in which 
the elementary tissues are less distinct, as the liver, the kidney, 
and even the lung; if we wish to determine, in this latter organ, 
the tissue in which tubercle is formed; if we attempt to discover 
in a liver affected with cirrhosis, or in a kidney affected with 
Bright's disease, the hypertrophy of one element of these organs 
and the atrophy of the other, we are liable to leave the domain of 
positive anatomy, and to enter upon a class of questions which 
are hardly susceptible of a definite solution.* 

B. Determination of the Lesion. — Having explained in what 
way the physician succeeds in discovering which is the affected 
organ, and to what extent it is affected, we will now consider the 
second point, viz. the manner in which it is affected, which compre- 
hends both the nature of the lesion and the progress it has made. 

* The correctness of this remark may be questioned, if we rightly understand 
the author's assertion. Can we avoid the conclusion that many lesions of the 
kidneys have been so accurately described by different authors, that in respect to 
them, we are in " the domain of positive anatomy," and that many questions 
have received that " definite solution " of which they are declared " insusceptible " 
in the text? The elaborate researches of Dr. Bright upon the pathological lesions 
exhibited by the kidneys, when affected by the disease that bears his name, 
surely announce to us many points within " the domain of positive anatomy." Dr. 
Prout, in his valuable work on Stomach and Renal Diseases, declares that " the 
post-mortem phenomena, when studied in connection with the condition of the 
urine and the constitutional symptoms, are quite sufficient, in a practical point of 
view, to regulate our proceedings and to show us in general, what we can and 
what we cannot accomplish." — (p. 178, 4th English edition ) The admirable 
work of M. Rayer, from which large quotations are made by Dr. Prout, (loc. 
supra cit.) may be mentioned in proof of how much " positive anatomy " can be 
claimed at the present time, in regard to renal lesions : (Traite des Maladies des 
Reins Atlas ) Nothing can be morp minute, but at the same time, what can be 
more accurate, than the description of the morbid appearances of the kidney affect- 
ed with granular degeneration. 1 (P